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theory"},{"term":"tappana"},{"term":"tarbi"},{"term":"taylor"},{"term":"tea"},{"term":"telehealth"},{"term":"theatre"},{"term":"thienprayoon"},{"term":"thurston"},{"term":"time"},{"term":"tinianov"},{"term":"toomey"},{"term":"transdisciplinary"},{"term":"transgender"},{"term":"transition"},{"term":"trapasso"},{"term":"trauma"},{"term":"triangulation"},{"term":"tribute"},{"term":"trust"},{"term":"twiter"},{"term":"uncertainty"},{"term":"unconscious"},{"term":"universe"},{"term":"upstairs"},{"term":"urology"},{"term":"van Meines"},{"term":"van mienes"},{"term":"vandekieft"},{"term":"veteran"},{"term":"video"},{"term":"volunteering"},{"term":"warraich"},{"term":"washington"},{"term":"weakness"},{"term":"webinar"},{"term":"whitburn"},{"term":"wollesen"},{"term":"young"},{"term":"young adult"},{"term":"zitter"}],"title":{"type":"text","$t":"Pallimed"},"subtitle":{"type":"html","$t":"Pallimed covers current palliative medicine, hospice, and end-of-life research and news, with a particular focus on publications not from the major palliative care journals.  It is aimed at health care professionals who work with people nearing the end of life."},"link":[{"rel":"http://schemas.google.com/g/2005#feed","type":"application/atom+xml","href":"https:\/\/www.pallimed.org\/feeds\/posts\/default"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/-\/fettig?alt=json-in-script\u0026max-results=6"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/search\/label\/fettig"},{"rel":"hub","href":"http://pubsubhubbub.appspot.com/"},{"rel":"next","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/-\/fettig\/-\/fettig?alt=json-in-script\u0026start-index=7\u0026max-results=6"}],"author":[{"name":{"$t":"Drew Rosielle MD"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/04345646798042773615"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"32","height":"32","src":"\/\/3.bp.blogspot.com\/-sdxTTBPb3Kw\/UddApiGn9-I\/AAAAAAAABLE\/mriu5xh44dA\/s113\/ea37b7645cd78e7867d246cd755bc8d4.jpeg"}}],"generator":{"version":"7.00","uri":"http://www.blogger.com","$t":"Blogger"},"openSearch$totalResults":{"$t":"63"},"openSearch$startIndex":{"$t":"1"},"openSearch$itemsPerPage":{"$t":"6"},"entry":[{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-7977450040031431789"},"published":{"$t":"2020-11-21T11:31:00.001-06:00"},"updated":{"$t":"2020-11-21T11:31:12.740-06:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"communication"},{"scheme":"http://www.blogger.com/atom/ns#","term":"covid"},{"scheme":"http://www.blogger.com/atom/ns#","term":"fettig"}],"title":{"type":"text","$t":"Addressing The Range of Patient Beliefs About COVID-19"},"content":{"type":"html","$t":"\u003Cdiv class=\"separator\" style=\"clear: both;\"\u003E\u003Ca href=\"https:\/\/1.bp.blogspot.com\/-u9xmnQcXuGM\/X7lNtlJJtjI\/AAAAAAAC_88\/-aK-QsnyTKIEgDbz-wGs-fM9JUC7zxoXwCLcBGAsYHQ\/s800\/did%2Byou%2Bhave%2Bto%2Bsay%2Byet.png\" style=\"display: block; padding: 1em 0; text-align: center; clear: right; float: right;\"\u003E\u003Cimg alt=\"\" border=\"0\" width=\"320\" data-original-height=\"800\" data-original-width=\"800\" src=\"https:\/\/1.bp.blogspot.com\/-u9xmnQcXuGM\/X7lNtlJJtjI\/AAAAAAAC_88\/-aK-QsnyTKIEgDbz-wGs-fM9JUC7zxoXwCLcBGAsYHQ\/s320\/did%2Byou%2Bhave%2Bto%2Bsay%2Byet.png\"\/\u003E\u003C\/a\u003E\u003C\/div\u003Eby Lyle Fettig (\u003Ca href=\"https:\/\/twitter.com\/FettigLyle\" target=\"_blank\"\u003E@FettigLyle\u003C\/a\u003E) \u003Cbr\u003E\u003Cbr\u003EI’ve been thinking about my role as a physician in responding to skepticism about a range of COVID topics, especially as we approach the holidays and all the tension about difficult recommendations to forgo traditional Thanksgiving dinners. As I think about our current situation, I can’t help but recall an encounter I had with a patient many years ago.  \u003Cbr\u003E\u003Cbr\u003EIn winter 2008 after President Obama was first elected, I saw a woman in clinic who said she was disappointed by the election result. She cited a jaw dropping falsehood about what she thought his election would mean for healthcare, and especially healthcare for white people. I was frankly shocked when she mentioned falsehood, as I had not heard her specific concern in the runup to the election. She had no history of psychosis or delusional thinking. We spent a while talking about her concerns, and why her healthcare was secure.  \u003Cbr\u003E\u003Cbr\u003EI remember thinking, \"where did she get this from and how could she believe this?\" The belief clearly had a racist element underpinning it. I felt powerless, as I couldn’t fix this person’s belief. But through a mixture of trust built on our relationship and exploring her underlying concerns, I think she ultimately listened to my reassurance that she would not lose her Medicare. And regardless of what she believed, it ultimately didn’t matter.  The truth was the truth. Her Medicare coverage wasn’t changing, and this truth would bear out for her regardless of her belief. \u003Cbr\u003E\u003Cbr\u003EDon't we have moments like this all the time, when patients bring up shocking beliefs\/myths\/etc about how the world works? Maybe not every day, but it happens a lot. People are not always well informed and have a mix of beliefs, born out of individual experiences, family background, and culture. “Groupthink” is a part of that culture.  \u003Cbr\u003E\u003Cbr\u003EWhen people bring up myths about their illness or healthcare itself, we usually deal with it one on one with the patient. We explore underlying concerns and try to address those concerns as best we can, either through communication or action.  \u003Cbr\u003E\u003Cbr\u003EDr. Fauci said he was \"stunned\" that so many see the pandemic as \"fake.\" I've also heard colleagues express disbelief about how lackadaisical many in the public are.  \u003Cbr\u003E\u003Cbr\u003EBut if you've been practicing medicine for a while, haven't you had enough people individually bring up wild ideas about how the world works to say, \"yeah, actually I'm not all that surprised.\" The piece that's hard is the group think, and that we have so little control over this groupthink, right here in front of us. So while I’m having a bit of disbelief, it isn't the main feeling I've been having. The main response is a bit of helplessness.  \u003Cbr\u003E\u003Cbr\u003EI feel helpless in the face of so many who aren't taking this seriously, and I'd guess many of you do, too. The only way forward for most of us is one patient at a time.  Sure, those who have a megaphone should continue to blast accurate and understandable public health messages. It's really important. The rest of us can amplify these messages. \u003Cbr\u003E\u003Cbr\u003EJust remember that you've been here before with patients' mistaken beliefs. One on one with patients and their families is where healthcare professionals have our greatest agency. We have the ability to understand \u003Ca href=\"https:\/\/thehealthcareblog.com\/blog\/2013\/06\/11\/the-patient-explanatory-model\/\" target=\"_blank\"\u003Eexplanatory models\u003C\/a\u003E, motivations, and concerns. \u003Cbr\u003E\u003Cbr\u003ENone of us would dispute that public health oriented restrictions come with hardships for many. When patients (or loved ones) express skepticism about public health guidance, resist the inclination to reinforce what you know to be true. By now, they have heard it all before! Explore how following public health guidance might be impacting their life in other ways (social isolation, loss of income, etc). This is what the restrictions actually mean for most people. This is harder to accomplish on social media or with family and friends, but you could give it a try there, too. \u003Cbr\u003E\u003Cbr\u003EExplore how they are talking about coronavirus and the restrictions with others around them. You'll hear about the groupthink. To go against the grain of one's in-group feels like a threat to their identity (even if the vast majority of the time, it isn’t a threat in that way). You will also hear a great deal about how families and friends are working together to overcome the conflicts that are inherent to trying to navigate these difficult times. Celebrate the work they are doing to do this when this happens! I’m definitely seeing this a fair amount in our palliative care clinic with our seriously ill patients and their families, who remain highly motivated to stay away from COVID. People have been very creative, having drive-by birthday celebrations at homes, etc. \u003Cbr\u003E\u003Cbr\u003EIF you can figure out how public health guidance impacts a person in potentially negative ways, then you can acknowledge that (and sometimes work to mitigate with help of social workers, etc). And then they may be more open to hearing you speak the truth about prevention. \u003Cbr\u003E\u003Cbr\u003EDon't expect them to change their mind instantly. Most of the impact of health care professional\/patient communication comes after a visit, and they may never tell you that you helped change their mind. As with all other healthcare, \"They don't care how much you know until they know how much you care.\" This maxim remains true with pandemic communication. If you’ve spoken your mind with compassion and respect, you’ve done your job, even if you can’t ultimately control what they do. \u003Cbr\u003E\u003Cbr\u003EThe pandemic has “stretched” my ability to separate what I can and can’t control. As we head into what looks like a dark winter, I hope we can all continue to find the light of our souls: Our ability to foster genuine human connection in the hardest of times.  \u003Cbr\u003E\u003Cbr\u003EP.S. Yes at the beginning of the pandemic \u003Ca href=\"https:\/\/www.pallimed.org\/2020\/03\/the-dizzying-experience-of-healthcare.html\" target=\"_blank\"\u003EI said we were going to war with coronavirus (see previous post\u003C\/a\u003E). Do I regret it? Yes and no. If I didn’t sorta regret it, I probably wouldn’t be bringing it up right now, as I might be the only person who actually remembers this.  I don’t like battle metaphors, I avoid them in practice unless patients bring them up. And I don’t want to be at war. So consider this post a bit of penance for “going there.” But I’ll admit to having mixed feelings about many different metaphors, even including battle metaphors. I think the downsides of battle metaphors mostly outweigh the upsides, but I can’t help to still think of it when it comes to the virus. So I’ll continue to wrestle with it, and accept non-violently any judgement silently cast by those who read my previous post. I get where you’re coming from, trust me. :)  \u003Cbr\u003E\u003Cbr\u003E\u003Ci\u003EDr. Lyle Fettig is an Assistant Professor of Clinical Medicine in the Department of Medicine\/Division of General Internal Medicine and Geriatrics. Dr. Fettig directs the IUSM Palliative Medicine Fellowship and works clinically with the Eskenazi Health Palliative Care Program.\u003C\/i\u003E\u003Cbr\u003E\u003Cbr\u003ENote - this post originated from a \u003Ca href=\"https:\/\/twitter.com\/FettigLyle\/status\/1329779036747337728?s=20\" target=\"_blank\"\u003Ethread by Lyle Fettig on Twitter\u003C\/a\u003E. \u003Cbr\u003E\u003Cbr\u003E\u003Cmeta name=\"twitter:card\" content=\"summary\" \/\u003E\u003Cmeta name=\"twitter:site\" content=\"@pallimed\" \/\u003E\u003Cmeta name=\"twitter:title\" content=\"Addressing The Range of Patient Beliefs About COVID-19\" \/\u003E\u003Cmeta name=\"twitter:description\" content=\"How should clinicians respond to patients expressing skepticism on COVID topics and guidance?\" \/\u003E\u003Cmeta name=\"twitter:image\" content=\"https:\/\/1.bp.blogspot.com\/-u9xmnQcXuGM\/X7lNtlJJtjI\/AAAAAAAC_88\/-aK-QsnyTKIEgDbz-wGs-fM9JUC7zxoXwCLcBGAsYHQ\/s800\/did%2Byou%2Bhave%2Bto%2Bsay%2Byet.png\" \/\u003E\u003Cmeta name=\"twitter:url\" content=\"POST URL HERE\" \/\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/7977450040031431789"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/7977450040031431789"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2020\/11\/addressing-range-of-patient-beliefs.html","title":"Addressing The Range of Patient Beliefs About COVID-19"}],"author":[{"name":{"$t":"Pallimed Editor"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/11358791266969988517"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/1.bp.blogspot.com\/-u9xmnQcXuGM\/X7lNtlJJtjI\/AAAAAAAC_88\/-aK-QsnyTKIEgDbz-wGs-fM9JUC7zxoXwCLcBGAsYHQ\/s72-c\/did%2Byou%2Bhave%2Bto%2Bsay%2Byet.png","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-2608534472070118584"},"published":{"$t":"2020-03-17T12:11:00.003-05:00"},"updated":{"$t":"2020-03-17T12:30:41.187-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"covid"},{"scheme":"http://www.blogger.com/atom/ns#","term":"emergency preparedness"},{"scheme":"http://www.blogger.com/atom/ns#","term":"fettig"}],"title":{"type":"text","$t":"The Dizzying Experience of Healthcare in the Time of a Pandemic"},"content":{"type":"html","$t":"\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Ca href=\"https:\/\/2.bp.blogspot.com\/-fDJuYsNbkac\/XnEIl9eJQPI\/AAAAAAACz_g\/I_rMkxNO9nA0Z_NDU6-xCwq-Wr8IhnRfACLcBGAsYHQ\/s1600\/plan%2Bfor%2Bthat.png\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"468\" data-original-width=\"467\" height=\"320\" src=\"https:\/\/2.bp.blogspot.com\/-fDJuYsNbkac\/XnEIl9eJQPI\/AAAAAAACz_g\/I_rMkxNO9nA0Z_NDU6-xCwq-Wr8IhnRfACLcBGAsYHQ\/s320\/plan%2Bfor%2Bthat.png\" width=\"319\" \/\u003E\u003C\/a\u003E\u003C\/div\u003EBy Lyle Fettig \u003Cu\u003E@fettiglyle\u003C\/u\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u003Ci\u003E\u003Ca href=\"https:\/\/www.pallimed.org\/p\/covid-19-pandemic-resources.html\"\u003ECheck out the Pallimed COVID-19 Resource page here. - Ed.\u003C\/a\u003E\u003C\/i\u003E \u003C\/span\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EI love the \u003Ca href=\"https:\/\/www.pallimed.org\/2020\/03\/a-letter-of-support-for-you-and.html\"\u003Eletter co-published by Pallimed and Geripal about COVID\u003C\/a\u003E,and you should read that too. As an erstwhile (for now) Pallimed contributor, I thought I'd toss in my two cents with some additional thoughts\/reflections based on week 1 of preparing for the COVID pandemic as a palliative care physician.\u003Cbr \/\u003EOver the last week, I've operated mentally in most of these lanes:\u003Cbr \/\u003E\u003Cstrong\u003E\u003Cbr \/\u003E\u003C\/strong\u003E\u003Cstrong\u003E1. Primary prevention and public health: \u003C\/strong\u003EThrough extensive advocacy for social distancing and widespread testing. I have talked about it with my patients and my own family and friends. This also included persistently calling governmental officials, pulling my sons out of school, writing letters, and re-entering social media after an over two year hiatus\u003Cbr \/\u003E\u003Cstrong\u003E\u003Cbr \/\u003E\u003C\/strong\u003E\u003Cb\u003E2.\u0026nbsp;\u003C\/b\u003E\u003Cstrong\u003EAssessmen\u003C\/strong\u003Et of patients with suspected COVID-19, like a person I've been following for 4-5 years who had pneumonia last year and called with complaint of a cough.  The usual clinical reasoning of the scenario was complicated as I tried to balance the desire to get him evaluated with the public health considerations.\u003Cbr \/\u003E\u003Cstrong\u003E\u003Cbr \/\u003E\u003C\/strong\u003E\u003Cstrong\u003E3. Management of mildly ill\u003C\/strong\u003E confirmed cases and mitigating the public health risk. Haven't dealt with this yet. Just waiting for the first call on one of my high risk clinic patients to have this. I know that even if they have mild symptoms, they might progress to lane 4.  It feels unfair to think that an emerging infectious disease would take any of their lives.\u003Cbr \/\u003E\u003Cstrong\u003E\u003Cbr \/\u003E\u003C\/strong\u003E\u003Cb\u003E4.\u0026nbsp;\u003C\/b\u003E\u003Cstrong\u003EManagement of seriously or critically ill patients who might die\u003C\/strong\u003E.  We've spent a lot of time with our critical care colleagues over the last week, swiftly trying to figure out what we would do with a \"surge\" and how it would change our usual collaboration, which is robust and well established. Enter the age of inpatient teleconsults, including a first: A surrogate asking me if he could email me a photo of himself so I could see what he looks like.\u003Cbr \/\u003E\u003Cstrong\u003E\u003Cbr \/\u003E\u003C\/strong\u003E\u003Cb\u003E5.\u0026nbsp;\u003C\/b\u003E\u003Cstrong\u003EWorst case scenario of resource allocation issues: \u003C\/strong\u003EWe hate talking about this, but it might happen, and we have to face it and be prepared.\u003Cbr \/\u003EIt's dizzying to think about all of these lanes, on top of the usual issues our patients and teams face. Lane 4 and 5 are scary enough to serve as motivation to put a lot of attention into lane 1.  Even though our ICU is a place with plenty of windows and sunlight, for some reason, I imagine lane 4 and 5 as a dark windowless place without walls, just a massive ward full of despair.  It's enough to move any of us to tears and action. \u003Cbr \/\u003EI've found it helpful, in conversation about the pandemic, to identify which lane we are talking about at that moment, especially with respect to lane 4 vs. 5.  In lane 5, there will be factors out of our control that determine whether patients get what they need.  Routine palliative care practice (fueled by extra coffee and fewer administrative meetings) will serve our patients and their families well. Under any circumstance, we will do what we can to support shared decision-making, even if there are factors out of our control (as there always are). \u003Cbr \/\u003E\u003Cbr \/\u003EHere are a few thoughts as we enter the new week:\u003Cbr \/\u003E\u003Cstrong\u003E\u003Cbr \/\u003E\u003C\/strong\u003E\u003Cstrong\u003ELet's keep advocating in lane 1 while we prepare  \u003C\/strong\u003E\u003Cbr \/\u003EIt's surreal to see cars on the road and just feel, well, disturbed.  After I finished pumping gas today, I wiped the handle off with Chlorox and went onto the next pump to wipe that one down too. (What have I become?)  We are still woefully under testing for SARS-CoV2. Still some people think this is a nothingburger. Continue to educate patiently and figure out what's hardest for them about social distancing, and empathize. I'm struggling with it.  I've been avoiding touching my family, changing clothes in the garage before entering, etc.  It's for the birds. \u003Cbr \/\u003E\u003Cstrong\u003E\u003Cbr \/\u003E\u003C\/strong\u003E\u003Cstrong\u003ERemember the concept of mortality salience and terror management theory\u003C\/strong\u003E\u003Cbr \/\u003EI'm scared.  For myself, for my own health.  It's tempered by probabilities, but you know, anecdotes.  I'm scared for my family's health, and my parents are hunkered down, not even allowed to touch their mail.  For the health and comfort of my current patients and their families.  For the suffering that our new patients in this time period of isolation.  Loneliness is already an epidemic, and the pandemic will amplify this.  \"Comfort and company\" is essential to the end of life experience, as one of my mentors Greg Sachs likes to say. The thought of having a large number of people dying in uber-isolation, swimming in PPE, without their families. \u003Cbr \/\u003E\u003Cbr \/\u003EI know I'm not alone.  I've talked to colleagues about the three levels of fear: for our patients, personal, and professional.  Everyone is walking around with extra fear.\u003Cbr \/\u003E\u003Cbr \/\u003EWhat does evidence for \u003Ca href=\"https:\/\/en.wikipedia.org\/wiki\/Terror_management_theory\"\u003ETerror Management Theory\u003C\/a\u003E suggest about what this will do to us?  When people are confronted with their mortality, there's evidence to suggest they act in heightened ways consistent with their own values. (There was the famous study where judges handed out worse punishments for criminals after being reminded of their own mortality) It may make us more protective of those values as well. In stressful times, there's more likely to be tension about little things. Pause and make sure you're not actually on the same page about the values. In times like this, there may be uncertainty about the best means to accomplish certain goals.  It helps to solidify agreement about the goal or value itself. \"What we both value is...\" This is the VitalTalk \"align\" statement from REMAP.  It works for us as well as our patients and families.\u003Cbr \/\u003E\u003Cstrong\u003E\u003Cbr \/\u003E\u003C\/strong\u003E\u003Cstrong\u003EDon't let perfection be the enemy of the good\u003C\/strong\u003E\u003Cbr \/\u003E\u003Cblockquote class=\"twitter-tweet\"\u003E\u003Cdiv dir=\"ltr\" lang=\"en\"\u003E\"Be fast, have no regrets.\"\u003Cbr \/\u003E\u003Cbr \/\u003EDr Michael J Ryan says \"the greatest error is not to move\" and \"speed trumps perfection\" when it comes to dealing with an outbreak such as \u003Ca href=\"https:\/\/twitter.com\/hashtag\/coronavirus?src=hash\u0026amp;ref_src=twsrc%5Etfw\"\u003E#coronavirus\u003C\/a\u003E.\u003Cbr \/\u003E\u003Cbr \/\u003EGet the latest on COVID-19 👉 \u003Ca href=\"https:\/\/t.co\/HMPNwaVk37\"\u003Ehttps:\/\/t.co\/HMPNwaVk37\u003C\/a\u003E \u003Ca href=\"https:\/\/t.co\/wDa7XOMw8Q\"\u003Epic.twitter.com\/wDa7XOMw8Q\u003C\/a\u003E\u003C\/div\u003E— Sky News (@SkyNews) \u003Ca href=\"https:\/\/twitter.com\/SkyNews\/status\/1238504143104421888?ref_src=twsrc%5Etfw\"\u003EMarch 13, 2020\u003C\/a\u003E\u003C\/blockquote\u003E\u003Cscript async=\"\" charset=\"utf-8\" src=\"https:\/\/platform.twitter.com\/widgets.js\"\u003E\u003C\/script\u003E \u003Cbr \/\u003E\u003Cstrong\u003ERemember the secret sauce of palliative care\u003C\/strong\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"https:\/\/2.bp.blogspot.com\/-vFN51D7hzRc\/XnEBdgvxVII\/AAAAAAACz_I\/vhzZ3pjDLQEDJ3eTmq1FpXCr2Ggq9IPuQCLcBGAsYHQ\/s1600\/Image_0.png\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"320\" data-original-width=\"560\" height=\"183\" src=\"https:\/\/2.bp.blogspot.com\/-vFN51D7hzRc\/XnEBdgvxVII\/AAAAAAACz_I\/vhzZ3pjDLQEDJ3eTmq1FpXCr2Ggq9IPuQCLcBGAsYHQ\/s320\/Image_0.png\" width=\"320\" \/\u003E\u003C\/a\u003EWhat's the secret sauce? There is more than one ingredient, but in addition to all the skilled professionals from various disciplines who bring compassion and persistence to care of individuals, I think the sauce is Relational Coordination.  Timely, accurate, frequent, and problem solving communication that is oriented around shared goals, shared knowledge, and mutual respect. Lean on these in the days and weeks ahead: With teammates, colleagues, hospital leaders, and most of all, patients and families. \u003Cbr \/\u003E\u003Cbr \/\u003ERelational coordination defines the collaboration between palliative care and critical care at many places, and I can't imagine my career without this collaboration. I have a deep admiration for the critical care physicians I work with, many who have become friends over the years, sharing in the care of some of our sickest and most vulnerable patients and their families.  Much has been written about avoiding war metaphors (with cancer and such), but I'm setting aside my pacifist ways for this virus.  We're going to war now, locked arm and arm against this tiny alien and the cascading effect on individuals and society.  The relationships built between colleagues will help us find our way through. \u003Cbr \/\u003ELet's save as many lives as we can and palliate this broken world along the way.   \u003Cbr \/\u003E\u003Cbr \/\u003EFlatten the curve, but when it hits, charge up the hill.\u003Cbr \/\u003E\u003Cbr \/\u003ESource for image 1: Meredith MacMartin\u003Cbr \/\u003ESource for image 2: \u003Ca href=\"https:\/\/heller.brandeis.edu\/relational-coordination\/\"\u003Ehttps:\/\/heller.brandeis.edu\/relational-coordination\/ \u003C\/a\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EDr. Lyle Fettig is an Assistant Professor of Clinical Medicine in the Department of Medicine\/Division of General Internal Medicine and Geriatrics. Dr. Fettig directs the IUSM Palliative Medicine Fellowship and works clinically with the Eskenazi Health Palliative Care Program.\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EFor more posts on \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/covid\"\u003ECOVID-19, click here.\u003C\/a\u003E\u003Cbr \/\u003EFor more posts on \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/emergency%20preparedness\"\u003EEmergency Preparedness, click here.\u003C\/a\u003E\u003Cbr \/\u003EFor more posts by \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/fettig\"\u003ELyle Fettig, click here\u003C\/a\u003E. \u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cmeta name=\"twitter:card\" content=\"summary\" \/\u003E\u003Cmeta name=\"twitter:site\" content=\"@pallimed\" \/\u003E\u003Cmeta name=\"twitter:title\" content=\"The Dizzying Experience of Healthcare in the Time of a Pandemic\" \/\u003E\u003Cmeta name=\"twitter:description\" content=\"Palliative medicine physician Lyle Fettig reviews some themes to focus on for clinicians working in a pandemic.\" \/\u003E\u003Cmeta name=\"twitter:image\" content=\"https:\/\/2.bp.blogspot.com\/-fDJuYsNbkac\/XnEIl9eJQPI\/AAAAAAACz_g\/I_rMkxNO9nA0Z_NDU6-xCwq-Wr8IhnRfACLcBGAsYHQ\/s1600\/plan%2Bfor%2Bthat.png\" \/\u003E\u003Cmeta name=\"twitter:url\" \/\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/2608534472070118584"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/2608534472070118584"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2020\/03\/the-dizzying-experience-of-healthcare.html","title":"The Dizzying Experience of Healthcare in the Time of a Pandemic"}],"author":[{"name":{"$t":"Lyle Fettig"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/00710388898582754749"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/2.bp.blogspot.com\/-fDJuYsNbkac\/XnEIl9eJQPI\/AAAAAAACz_g\/I_rMkxNO9nA0Z_NDU6-xCwq-Wr8IhnRfACLcBGAsYHQ\/s72-c\/plan%2Bfor%2Bthat.png","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-6558355433366647559"},"published":{"$t":"2017-03-01T13:56:00.000-06:00"},"updated":{"$t":"2018-08-31T08:01:40.713-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"book"},{"scheme":"http://www.blogger.com/atom/ns#","term":"book review"},{"scheme":"http://www.blogger.com/atom/ns#","term":"depression"},{"scheme":"http://www.blogger.com/atom/ns#","term":"fettig"},{"scheme":"http://www.blogger.com/atom/ns#","term":"humanity"},{"scheme":"http://www.blogger.com/atom/ns#","term":"media"},{"scheme":"http://www.blogger.com/atom/ns#","term":"mindfulness"},{"scheme":"http://www.blogger.com/atom/ns#","term":"review"},{"scheme":"http://www.blogger.com/atom/ns#","term":"The profession"}],"title":{"type":"text","$t":"Bringing Humanity Back to Medicine: A Book Review of \"Attending\" by Ronald Epstein"},"content":{"type":"html","$t":"\u003Ca href=\"http:\/\/amzn.to\/2lXpQ8l\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" height=\"320\" src=\"https:\/\/3.bp.blogspot.com\/-DVuRykGaD0I\/WLclQi2ogEI\/AAAAAAABsiM\/2xtbqV4ESRsVIIm_nUwLUqpYHS47n86jgCLcB\/s320\/Book%2BReview-%2BHow%2BWe%2BDie%2B-%2BSQ%2B%25281%2529.png\" width=\"320\" \/\u003E\u003C\/a\u003E by Lyle Fettig\u003Cbr \/\u003E\u003Cbr \/\u003EWhen debriefing after a difficult communication encounter led by a fellow or resident, I’ll often start by asking the trainee, “how do you think it went?” There are times when I thought the encounter went very well, yet the trainee leaves the room with a worried look. Perhaps the trainee clearly explained the medical facts, demonstrated ample empathy, and carefully talked about the next steps, so I’ll be a bit surprised when the trainee says, “It went horrible.” I’ll ask why, and I’ll get a bemused look in response. “Because I made the patient cry,” the trainee might say. Usually, when this happens, the trainee knows that it was the serious news that made the patient cry: A change in condition, a revelation about prognosis, etc. Deliberate reflection on skillful communication requires some understanding that while patients may respond differently to various communication techniques, we are ultimately not responsible for the patient’s emotional response to serious information. Even if giving the information was the ethical and pragmatic way to proceed, the physician is at risk for experiencing strong emotions that mirror those of the patient’s. The response of the patient and the physician’s experience of observing the response might make some second guess whether they have approached the conversation skillfully, even when they have.\u003Cbr \/\u003E\u003Ca href=\"http:\/\/umkc%20swinney%20recreational%20center5030%20holmes%2c%20kc%2c%20mo%2064110\/\" target=\"_blank\"\u003E\u003Cbr \/\u003E\u003C\/a\u003E \u003Ca href=\"http:\/\/www.ronaldepstein.com\/attending\" target=\"_blank\"\u003E“Attending: Medicine, Mindfulness, and Humanity” by Dr. Ronald Epstein\u003C\/a\u003E, professor of family medicine and palliative care at the University of Rochester, is all about how physicians cognitively and emotionally process not only moments like this one, but also the more routine moment to moment emotional roller coaster of the practice of medicine. It’s a practice that is rich with cognitive complexity but always mingling with emotional intensity: Anxiety over making correct diagnoses or missing something. Frustration about electronic medical record systems. Helplessness when faced with symptoms we cannot explain, or sometimes cannot alleviate adequately.\u003Cbr \/\u003E\u003Cbr \/\u003EWe all experience these thoughts and emotions in our own way, and all develop methods (sometimes adaptive, sometimes not so adaptive) to respond to our inner experience. Dr. Epstein blends a mix of his own experience (which he describes with vulnerable humility), the experience of colleagues, and a description of some of his own research (\u003Ca href=\"http:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/184621\" target=\"_blank\"\u003Eexample here\u003C\/a\u003E) as well as related research in neuroscience, decision-science, and resiliency. The result is a readable, thought-provoking, useful, and comforting book that I’d recommend to any physician, or for that matter, any health care professional.\u003Cbr \/\u003E\u003Cbr \/\u003EThe book starts with a chapter on mindfulness in the practice of medicine and then a chapter on the related concept of “Attending” which describes our human ability to attend to a limited number of stimuli at once, leading to \u003Ca href=\"http:\/\/www.pallimed.org\/2013\/04\/basketball-presence-of-suffering-and.html?m=0\" target=\"_blank\"\u003Einattentional blindnes\u003C\/a\u003Es (which none of us are immune to), and why this contributes to the challenges of medical diagnosis and management as well as why it may be so hard for us to recognize the experience of the patient at times. Even for people who are highly empathic, there’s still a risk of losing sight of the other person’s perspective when you’re lost in clinical reasoning, etc. He then further expands the discussion to the topic of uncertainty, and how we in medicine are certainty junkies, which brings with it a risk for crowding out curiosity. And that has negative implications.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"http:\/\/amzn.to\/2lXpQ8l\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" height=\"320\" src=\"https:\/\/2.bp.blogspot.com\/-tDljSeA39cU\/WLclDPB4r3I\/AAAAAAABsiI\/XrmJ8bPNEDAC35xVlUIHuDHQvbS7ty3rQCLcB\/s320\/ronaldepstein-attending.jpg\" width=\"211\" \/\u003E\u003C\/a\u003EPalliative care clinicians will especially appreciate his reflections on the concept of “presence” or “bonded resonance” in which two people are in touch and in tune with each other. Quoting philosopher Ralph Harper, he talks about the important role of presence in “boundary situations,” times of vulnerability and uncertainty. Philosophers and scientists alike have explored this resonance, and he describes two seemingly competing, but perhaps complementary, theories for how this happens. The first is “theory of mind,” where it’s thought that we theorize what might be going on in other’s minds, and might occasionally verify in communication if we understand their thoughts and feelings. The other theory is “embodied simulation” which posits that we “relive in our own bodies and minds the actions and presumed intentions of the other. He states that the current body of research comes to an intuitive conclusion: our cognitive and emotional lives are shared psychologically and neurobiologically, and boundaries between those sharing in presence are blurred.\u003Cbr \/\u003E\u003Cbr \/\u003EThis is a wonderment, and it reframes the feeling of dread that often goes along with breaking bad news. Yes, it's the information that makes the patient cry. It's information that the physician shares from his or her own mind to the patient's, who reciprocates with sharing emotion back to the physician. Although the physician has not \"caused\" the bad news, perhaps the feeling of responsibility for the patient's emotions stems from the blurring of boundaries?\u003Cbr \/\u003E\u003Cbr \/\u003EI eagerly read the chapters on “Responding to Suffering” and “The Shaky State of Compassion” and agree with his supposition that while training in empathy is important, it only goes so far and there’s a real risk of emotional contagion- taking on the patient’s distress. Describing research about compassion, he describes “exquisite empathy” or compassionate action that may relieve the patient’s suffering and in concert, release the emotional tension that the clinician experiences.\u0026nbsp; (I would include plans that\u0026nbsp;come about after careful goals of care discussions as \"compassionate actions\",\u0026nbsp;and even the process itself, that involves a lot of sitting with patients and grappling.)\u0026nbsp;The good news is that there is growing data that compassion can be cultivated through practices such as loving-kindness meditation.\u003Cbr \/\u003E\u003Cbr \/\u003EThe book closes with chapters on resiliency in both the individual clinician and in the healthcare system with compassionate suggestions for his colleagues that don’t aim to “fix” the problems of our broken healthcare system, but do aim to help us build capacity to respond to it. Everything he writes about complements, integrates with, and bolsters important communication skills commonly taught by palliative care clinicians.\u003Cbr \/\u003E\u003Cbr \/\u003EYou’ll have to read the book to see some of his suggestions, but I’ll leave this review on a personal note. I personally am not immune to burnout and anxiety, as well as occasional dysthymia and rarely, depression. I remember when I was just starting, our team’s chaplain asked me to notice my breathing in the middle of a visit with a very anxious man who was in pain as well. To my surprise, I was holding my breath, perhaps an embodied simulation of what I witnessed. I think of the multitude of simulations we process each day, with patients, their families…and with colleagues, and this is a timely book for our field and for medicine in general.\u003Cbr \/\u003E\u003Cbr \/\u003EI think this book offers a framework to consider how we might become more resilient, yet I recognize that someone out there might be reading this right now in the midst of a personal crisis. If that's the case, I could imagine that hope might not come as easily as you would want.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003ESo, I have one last heartfelt note for everyone, but especially for my physician colleagues. It comes from the experience in the past couple of years of losing a physician colleague to suicide.\u003C\/b\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cstrong\u003ERecent research indicates that burnout in HPM physicians is \u003C\/strong\u003E\u003Ca href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/26620234\"\u003E\u003Cstrong\u003Esomething we should pay attention to carefully.\u003C\/strong\u003E\u003C\/a\u003E\u003Cstrong\u003E\u0026nbsp; It's an issue in medicine more broadly. \u003Cspan style=\"color: #0066cc;\"\u003E\u003Cspan style=\"color: black;\"\u003EPhysicians have higher rates of burnout, depressive symptoms, and suicide risk than the general population\u003C\/span\u003E.\u003C\/span\u003E\u0026nbsp;\u003C\/strong\u003E\u003Ca href=\"https:\/\/afsp.org\/our-work\/education\/physician-medical-student-depression-suicide-prevention\/\" target=\"_blank\"\u003E\u003Cstrong\u003EAn estimated 300–400 physicians die by suicide in the U.S. per year.\u0026nbsp;\u003C\/strong\u003E\u003C\/a\u003E\u003Cstrong\u003E Don't wait until a crisis point, it's ok to think of it as a quality of life issue!\u0026nbsp; Seek help if you are suffering. You may feel shame, but that's part of having depression and not because of who you are.\u003C\/strong\u003E\u003Cbr \/\u003E\u003Cb\u003E\u003Cbr \/\u003E\u003C\/b\u003E \u003Cb\u003EThere are likely resources available to you locally at your own institution or in your community. If you are in crisis, you can also call the \u003Ca href=\"http:\/\/suicidepreventionlifeline.org\/\" target=\"_blank\"\u003ENational Suicide Prevention Lifeline at 1-800-273-8255\u003C\/a\u003E. There is no shame at all in reaching out- we need you in this world.\u003C\/b\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EI'll leave everyone with a \u003Ca href=\"http:\/\/www.fresno.va.gov\/docs\/Transcript_Lovingkindness_Meditation_.pdf\" target=\"_blank\"\u003Eloving-kindness meditation\u003C\/a\u003E:\u003Cbr \/\u003EMay you be filled with loving kindness...\u003Cbr \/\u003EMay you be held in loving kindness...\u003Cbr \/\u003EMay you feel my love now...\u003Cbr \/\u003EMay you accept yourself just as you are...\u003Cbr \/\u003EMay you be happy...\u003Cbr \/\u003EMay you know the natural joy of being alive...\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EDr. Lyle Fettig is an Assistant Professor of Clinical Medicine in the Department of Medicine\/Division of General Internal Medicine and Geriatrics. Dr. Fettig directs the IUSM Palliative Medicine Fellowship and works clinically with the Eskenazi Health Palliative Care Program.\u003C\/i\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/6558355433366647559"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/6558355433366647559"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2017\/03\/bringing-humanity-back-to-medicine-book.html","title":"Bringing Humanity Back to Medicine: A Book Review of \"Attending\" by Ronald Epstein"}],"author":[{"name":{"$t":"Lyle Fettig"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/00710388898582754749"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/3.bp.blogspot.com\/-DVuRykGaD0I\/WLclQi2ogEI\/AAAAAAABsiM\/2xtbqV4ESRsVIIm_nUwLUqpYHS47n86jgCLcB\/s72-c\/Book%2BReview-%2BHow%2BWe%2BDie%2B-%2BSQ%2B%25281%2529.png","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-7300069576464136344"},"published":{"$t":"2015-03-08T23:50:00.000-05:00"},"updated":{"$t":"2015-03-09T00:18:42.344-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"fettig"}],"title":{"type":"text","$t":"Finding Meaning through Writing: Lisa Bonchek Adams"},"content":{"type":"html","$t":"by Lyle Fettig\u003Cbr \/\u003E\u003Cdiv\u003E\u003Cbr \/\u003EI regret not writing sooner.\u003Cbr \/\u003E\u003Cbr \/\u003ELisa Bonchek Adams, a writer, died last Friday.  I regret not telling her how moved I was by her writing, and I admit I have only read a small fraction of \u003Ca href=\"http:\/\/lisabadams.com\/blog\/\"\u003Eher blog\u003C\/a\u003E.\u003Cbr \/\u003E\u003Cbr \/\u003EAlmost two years ago, she posted \"\u003Ca href=\"http:\/\/lisabadams.com\/2013\/04\/18\/floating-away\/\"\u003EFloating Away\u003C\/a\u003E\" which found its way to me through Twitter. As I read\u003Cspan style=\"font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;\"\u003E\u0026nbsp;Lisa's writing, the thought occurred to me, \"You know, if I had a serious illness, I'd probably want to write more. Writing would bring meaning to me through exploring the experience.\"\u003C\/span\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EThe past several summers, my wife and I have traveled to Northern Michigan with our boys to seek refuge from the humid Midwestern summer.  It's a resumption of a family tradition from my youth when I would travel with my parents, brother and sister to visit my dad's family.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ctable cellpadding=\"0\" cellspacing=\"0\" class=\"tr-caption-container\" style=\"float: right; margin-left: 1em; text-align: right;\"\u003E\u003Ctbody\u003E\u003Ctr\u003E\u003Ctd style=\"text-align: center;\"\u003E\u003Ca href=\"http:\/\/2.bp.blogspot.com\/-wMNPInnYf-Y\/VPwBPpRkuoI\/AAAAAAAADjk\/a6Z-3LlQTFQ\/s1600\/4766098862_db9d5971c2_b.jpg\" imageanchor=\"1\" style=\"clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;\"\u003E\u003Cimg border=\"0\" src=\"http:\/\/2.bp.blogspot.com\/-wMNPInnYf-Y\/VPwBPpRkuoI\/AAAAAAAADjk\/a6Z-3LlQTFQ\/s1600\/4766098862_db9d5971c2_b.jpg\" height=\"212\" width=\"320\" \/\u003E\u003C\/a\u003E\u003C\/td\u003E\u003C\/tr\u003E\u003Ctr\u003E\u003Ctd class=\"tr-caption\" style=\"text-align: center;\"\u003E\u003Cspan style=\"font-size: xx-small;\"\u003ESunset, Petoskey, MI State Park from Fickr user dustin_j_williams\u003C\/span\u003E\u003C\/td\u003E\u003C\/tr\u003E\u003C\/tbody\u003E\u003C\/table\u003EAs I sat on the beach last summer, I thought about \"Floating Away.\"  It seemed impossible that I was the same age my mother was when I was eight years old. I remember the joy of running into the crashing yet relatively subtle Lake Michigan waves. At eight, my future on earth seemed as horizonless as the blue water.  Every time I would run into the cool water, I would shiver, momentarily forgetting the transient nature of this discomfort as my body adjusted.  While I gleefully jumped through the waves, I would think about how life might be in the 21st century.  I could never really wrap my mind around it, but I just knew it would be different in fantastic ways that could not be predicted.   \u003Cbr \/\u003E\u003Cbr \/\u003EAt 39, my elder son replaced me as the eight-year old. \u0026nbsp;I noted how the scene around me had changed little since the time I was his age. The dunes to the left looked untouched like the font on the signs leading to the beach house. As I looked around at my family, my parents, brother, sister and their families, I was grateful to be together in this way.  I thought about my patients and the loss they and their families experienced.  The stability of the scene in front of me might have fooled me if not for my age. \u0026nbsp;I can start to convince myself that 1983 was a long time ago. \u0026nbsp;The average birth date of my patients predictably trends closer to mine. \u0026nbsp; Sadness momentarily overwhelmed me.\u0026nbsp; \u003Cbr \/\u003E\u003Cbr \/\u003EDeath is like a wall that forces us to turn around and look back.*  What we see is our life and the meaning brought by having lived it. \u0026nbsp;With this hopefully comes gratitude but also the possibility for regret or guilt. Time is precious. \u0026nbsp;Is there a metric to determine the wisdom of time spent over a life? Uncertainty and imperfection make self-forgiveness important.\u003Cbr \/\u003E\u003Cbr \/\u003EI faced the lake and pondered the landscape behind me.  My mind wandered through hills that led to the farm where my father grew up. \u0026nbsp;The hills connect to roads leading to the other side of the lake and the urban beaches my mother frequented when she was young.  The roads branch like capillaries to feed a sprawling, disorganized series of places which make up the vital organs of my life. When the clouds allow, I imagine the sun radiantly warms all simultaneously.\u003Cbr \/\u003E\u003Cbr \/\u003EA cloud moved just enough to bring warmth.  The water glistened and it's a moment of beauty which felt familiar, a moment in time I have lived before. I felt home.   \u003Cbr \/\u003E\u003Cblockquote class=\"twitter-tweet\" lang=\"en\"\u003EFind a bit of beauty in the world today. Share it. If you can't find it, create it. Some days this may be hard to do. Persevere.\u003Cbr \/\u003E— Lisa Bonchek Adams (@AdamsLisa) \u003Ca href=\"https:\/\/twitter.com\/AdamsLisa\/status\/570894713802366976\"\u003EFebruary 26, 2015\u003C\/a\u003E\u003C\/blockquote\u003E\u003Cscript async=\"\" charset=\"utf-8\" src=\"\/\/platform.twitter.com\/widgets.js\"\u003E\u003C\/script\u003E I yearn for more moments like this and am quite hopeful for them.  That Lisa Bonchek Adams cannot actively create or experience more beautiful moments is a cause for grief for her her family and friends, both near and far. \u0026nbsp;To the world, she leaves behind a trail of writing which opens a door to find more than a bit of beauty.\u0026nbsp; Having followed \u003Ca href=\"https:\/\/twitter.com\/AdamsLisa\"\u003E@adamslisa on Twitter\u003C\/a\u003E, I know that recent times have been anything but easy.\u0026nbsp; Writing could not have alleviated all of her suffering, but hopefully she found meaning and beauty from it. \u003Cbr \/\u003E\u003Ctable cellpadding=\"0\" cellspacing=\"0\" class=\"tr-caption-container\" style=\"float: left; margin-right: 1em; text-align: left;\"\u003E\u003Ctbody\u003E\u003Ctr\u003E\u003Ctd style=\"text-align: center;\"\u003E\u003Ca href=\"http:\/\/2.bp.blogspot.com\/-Ps8134S2NlY\/VPx3Y_1-KwI\/AAAAAAAADj0\/A3O1XTFFKEY\/s1600\/photo.JPG\" imageanchor=\"1\" style=\"clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;\"\u003E\u003Cimg border=\"0\" src=\"http:\/\/2.bp.blogspot.com\/-Ps8134S2NlY\/VPx3Y_1-KwI\/AAAAAAAADj0\/A3O1XTFFKEY\/s1600\/photo.JPG\" height=\"200\" width=\"105\" \/\u003E\u003C\/a\u003E\u003C\/td\u003E\u003C\/tr\u003E\u003Ctr\u003E\u003Ctd class=\"tr-caption\" style=\"text-align: center;\"\u003E\u003Cspan style=\"font-size: xx-small;\"\u003EIndianapolis Today\u003C\/span\u003E\u003C\/td\u003E\u003C\/tr\u003E\u003C\/tbody\u003E\u003C\/table\u003E\u003Cbr \/\u003EMoments of beauty require recognition by the observer, and Lisa's quote above serves as a reminder. \u0026nbsp;The observer can create favorable circumstances for beauty to arise by how she lives her life. The wall forces the observer to turn around and look, but then she looks forward to the terrain in front of her to decide which paths to take. \u0026nbsp;The ultimate arrival of the wall is elusively out of her control.\u003Cbr \/\u003E\u003Cbr \/\u003EI still like to believe that if I were seriously ill, I would write about it. How foolish am I though. \u0026nbsp;I am someone who need not turn to the internet to witness the fragility of human existence. \u0026nbsp;My initial interpretation of my inner voice as I read Lisa's blog was incorrect. The corrected version reads:\u003Cbr \/\u003E\u003Cbr \/\u003EIf I am to be alive, I should write about the experience.  That would bring meaning to me. \u003Cbr \/\u003E\u003Cblockquote class=\"twitter-tweet\" lang=\"en\"\u003EMake the most of this day. Whatever that means to you, whatever you can do, no matter how small it seems.\u003Cbr \/\u003E— Lisa Bonchek Adams (@AdamsLisa) \u003Ca href=\"https:\/\/twitter.com\/AdamsLisa\/status\/570894880110710784\"\u003EFebruary 26, 2015\u003C\/a\u003E\u003C\/blockquote\u003E\u003Cspan style=\"background-color: white; border: 0px; font-family: 'Helvetica Neue', Arial, sans-serif; font-size: 12px; line-height: 22px; margin: 0px; padding: 0px;\"\u003E\u003Cspan style=\"border-image-outset: initial; border-image-repeat: initial; border-image-slice: initial; border-image-source: initial; border-image-width: initial; border: 0px; font-size: xx-small; margin: 0px; padding: 0px;\"\u003E\u003Ci\u003ELyle Fettig (\u003C\/i\u003E\u003Ca href=\"https:\/\/twitter.com\/lfettig\" style=\"border-image-outset: initial; border-image-repeat: initial; border-image-slice: initial; border-image-source: initial; border-image-width: initial; border: 0px; color: #1f5a09; font-style: italic; margin: 0px; padding: 0px;\"\u003E@lfettig\u003C\/a\u003E\u003Ci\u003E) is a palliative care doctor in Indianapolis where he lives with his wife and two boys.\u0026nbsp;\u003C\/i\u003E\u003C\/span\u003E\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"background-color: white; border: 0px; font-family: 'Helvetica Neue', Arial, sans-serif; font-size: 12px; line-height: 22px; margin: 0px; padding: 0px;\"\u003E\u003Cspan style=\"border-image-outset: initial; border-image-repeat: initial; border-image-slice: initial; border-image-source: initial; border-image-width: initial; border: 0px; font-size: xx-small; margin: 0px; padding: 0px;\"\u003E\u003Ci\u003E\u003Cspan style=\"font-family: 'Helvetica Neue', Arial, sans-serif;\"\u003E*\u003C\/span\u003EHe thanks Dr. William Breitbart, psychiatrist and Chair of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center (where coincidentally, Lisa received much of her care). \u0026nbsp;Dr. Breitbart presented a Keynote entitled  “Meaning-Centered Psychotherapy: Meaning and Spirituality in End of Life Care”  at the \u003Ca href=\"http:\/\/www.iupui.edu\/~irespect\/2015-Conference.html\"\u003E2015 IUPUI RESPECT Conference\u003C\/a\u003E. He introduced the existentialist metaphor of \"death as a wall\" during his comments. The \u003Ca href=\"http:\/\/jco.ascopubs.org\/content\/early\/2015\/01\/28\/JCO.2014.57.2198.abstract\"\u003Erecent RCT on Meaning-Centered Group Psychotherapy\u003C\/a\u003E by Breitbart and others is worth a read and deserves a blog post on it's own.\u003C\/i\u003E\u003C\/span\u003E\u003C\/span\u003E\u003Cbr \/\u003E\u003Cscript async=\"\" charset=\"utf-8\" src=\"\/\/platform.twitter.com\/widgets.js\"\u003E\u003C\/script\u003E \u003C\/div\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/7300069576464136344"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/7300069576464136344"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2015\/03\/finding-meaning-through-writing-lisa.html","title":"Finding Meaning through Writing: Lisa Bonchek Adams"}],"author":[{"name":{"$t":"Lyle Fettig"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/00710388898582754749"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"http:\/\/2.bp.blogspot.com\/-wMNPInnYf-Y\/VPwBPpRkuoI\/AAAAAAAADjk\/a6Z-3LlQTFQ\/s72-c\/4766098862_db9d5971c2_b.jpg","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-2851300209791806809"},"published":{"$t":"2015-03-02T09:06:00.000-06:00"},"updated":{"$t":"2021-04-06T23:28:56.146-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"AAHPM"},{"scheme":"http://www.blogger.com/atom/ns#","term":"communication"},{"scheme":"http://www.blogger.com/atom/ns#","term":"fettig"},{"scheme":"http://www.blogger.com/atom/ns#","term":"learner"},{"scheme":"http://www.blogger.com/atom/ns#","term":"medical student"},{"scheme":"http://www.blogger.com/atom/ns#","term":"The profession"}],"title":{"type":"text","$t":"Atul Gawande's Gifts to Palliative Care and Rethinking How to Teach with Tact"},"content":{"type":"html","$t":"by Lyle Fettig, MD\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"http:\/\/www.visitphilly.com\/resize\/587x391\/166\/r\/http\/photos.visitphilly.com\/flower-show-overview-2014-rkennedy-600\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" src=\"http:\/\/www.visitphilly.com\/resize\/587x391\/166\/r\/http\/photos.visitphilly.com\/flower-show-overview-2014-rkennedy-600\" height=\"213\" width=\"320\" \/\u003E\u003C\/a\u003ELet me tell you about a palliative care colleague.\u0026nbsp; His office is next to mine.\u0026nbsp; If both of our doors are open, I can hear his phone conversations.\u0026nbsp; Occasionally, I'll recognize when he's having a challenging conversation.\u0026nbsp; My ears especially perk up when the challenging conversation is with a physician colleague.\u0026nbsp; I cannot detect it by the volume, pitch, or tone of his voice.\u0026nbsp; He varies all of those features as he would in normal conversation even though the topic is more tense.\u003Cbr \/\u003E\u003Cbr \/\u003EHere's what I notice as I listen:\u003Cbr \/\u003E\u003Cul\u003E\u003Cli\u003EHe uses more open ended questions than usual, aiming to clarify the other doctor's position and concerns.\u003C\/li\u003E\u003Cli\u003EHe uses more silence.\u0026nbsp; I can hear him patiently listening and never interrupting.\u003C\/li\u003E\u003Cli\u003EI hear statements of appreciation for the role the other physician is playing in the patient's care and\/or the relationship the physician has with the patient.\u003C\/li\u003E\u003Cli\u003EWhen there are areas of disagreement, he makes clear statements of the intention which underlies his position.\u0026nbsp; The intentions are almost uniformly statements that represent interests of the patient.\u0026nbsp;\u0026nbsp;\u003C\/li\u003E\u003Cli\u003EWhen he makes suggestions, he doesn't represent them as a matter of doctrine.\u0026nbsp; \u003C\/li\u003E\u003C\/ul\u003EI learn from listening to him.\u0026nbsp; He turns the conversation into a \"learning conversation.\"\u0026nbsp; Does this approach always resolve the issue to his satisfaction?\u0026nbsp; No. But it frequently does.\u0026nbsp; And in the process, he's building relationships with colleagues who might otherwise be skeptical.\u0026nbsp; If we talk about these challenging conversations, he always seems to give the other person the benefit of the doubt regarding their intentions. He doesn't just take this approach with challenging colleagues though.\u0026nbsp; Whether it's our interdisciplinary team, our fellows, or a junior medical student, he consistently brings these ingredients. \u0026nbsp; \u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EHumble and Curious\u003C\/b\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EThe first adjective which comes to mind when I think of Atul Gawande is eloquent. \u0026nbsp;The masterfully written\u0026nbsp;\u003Ca href=\"http:\/\/atulgawande.com\/book\/being-mortal\/\"\u003E\u003Ci\u003EBeing Mortal \u003C\/i\u003E\u003C\/a\u003Ewould not have been possible without his eloquence.\u0026nbsp; After reading the book, watching the \u003Ca href=\"http:\/\/www.pbs.org\/wgbh\/pages\/frontline\/being-mortal\/\"\u003EFrontline episode\u003C\/a\u003E, and now hearing him at the AAHPM Annual Assembly, humble and curious also rise to the forefront. Gawande recognized he could improve his own skill in approaching conversations with seriously ill patients.\u0026nbsp; He sought out those who have expertise, namely his palliative care colleagues at Dana-Farber\/Brigham and Women's Cancer Center.\u0026nbsp; And he exercised his curiosity to learn.\u003Cbr \/\u003E\u003Cbr \/\u003EDuring the Q\/A at his plenary session, Gawande was asked:\u003Cbr \/\u003E\u003Cblockquote class=\"tr_bq\"\u003E\u003Ci\u003E\"Do you ever get ANGRY at physicians who torture their dying patients?  Sure they weren't \"trained\" in communication, but they are human.\"\u003C\/i\u003E\u003C\/blockquote\u003EGawande answered by reflecting on his own imperfection.\u0026nbsp; (People in glass houses shouldn't throw stones.)\u0026nbsp; He then framed the challenge that is before our field of hospice and palliative care:\u003Cbr \/\u003E\u003Cblockquote class=\"tr_bq\"\u003E\u003Ci\u003E\"The most interesting problems are those in which good people do bad things.\"*\u003C\/i\u003E\u003C\/blockquote\u003EThose physicians who do this poorly ARE only human, after all.\u0026nbsp; Most (or should I say all?) grew up in a culture where death is the enemy, it's hard to talk about, and then went to medical schools where they were exposed to a hidden curriculum which reduced their capacity for empathy.\u0026nbsp; We may feel angry when things go poorly and we can't fix it, but it's also important to make sure we're pointing our finger at the right problems.\u0026nbsp; The \"torturing physician\" likely has inadequate skill or capacity to approach the situation fruitfully, and may lack the \u0026nbsp;systematic infrastructure to make up for the inadequacy.\u0026nbsp; We only see the end result of a culture and healthcare system not designed for proficiency in this area.\u0026nbsp; The physician isn't a bad person- more likely quite the opposite.\u003Cbr \/\u003E\u003Cbr \/\u003ECommandment #8 of the \u003Ca href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/6615097\"\u003E\u003Ci\u003ETen Commandments for Effective Consultation\u003C\/i\u003E\u003C\/a\u003E is \"Teach with Tact.\"\u0026nbsp; When describing this commandment, the oft-cited original article mostly focuses on how to leave recommendations. The authors give solid advice about providing references of evidence to the primary physician in a timely manner. \"The patient may quote the article to the primary physician....few physicians enjoy expanding their horizons in this matter.\" \u0026nbsp;Part of our humanity is the desire to always fulfill our physician role as expert, even when we aren't always the expert.\u003Cbr \/\u003E\u003Cbr \/\u003EWe can hope that other physicians will naturally follow Gawande's lead and use their capacity for humility and curiosity to learn from our field.\u0026nbsp; Make a list of those surgeons, oncologists, critical care specialists, hospitalists and others who exhibit these capacities.\u0026nbsp; You may be surprised how long the list already is.\u003Cbr \/\u003E\u003Cbr \/\u003EWhat about those that don't exude humility and curiosity?\u0026nbsp; What about those times when we feel angry?\u003Cbr \/\u003E\u003Cbr \/\u003EBob Arnold \u003Ca href=\"http:\/\/hospitals.jefferson.edu\/~\/media\/pdfs\/departments\/palliative%20care\/consultationetiquettechallengespalliativecare.pdf\"\u003Eprovides the following wise advice\u003C\/a\u003E:\u003Cbr \/\u003E\u003Cblockquote class=\"tr_bq\"\u003E\u003Ci\u003E\"The learning point is how to listen respectfully, assume they know something about the patient, and be humble in my suggestions,” Arnold says. “We need to be as kind to our primary clients, the referring physicians, when they don’t do what we think they should, as we are toward patients and families who make different choices than we would.  If I can ask myself why a smart, hard-working doctor would want to do things differently than I would, I can be a better advocate for the patient and help the doctor provide better care for that patient.\"\u0026nbsp;\u0026nbsp;  \u003C\/i\u003E\u003C\/blockquote\u003EWe need to carefully consider how to teach with tact.\u0026nbsp; We need to skillfully teach with humility and curiosity, gently guiding rather than brashly imparting. \u0026nbsp; Remember what Chester Elton said during his Thursday plenary session as he quoted his father, \"You be nice to everybody, because everybody is having a tough day.\"\u0026nbsp; Empathy isn't just for our patients.\u0026nbsp; Horizons won't expand through lambast and lecture.\u003Cbr \/\u003E\u003Cbr \/\u003EMy palliative care colleague probably sounds familiar to you.\u0026nbsp; You hopefully have colleagues who exhibit the same humility, curiosity, and equanimity.\u0026nbsp; And not just them.\u0026nbsp; You too.\u003Cbr \/\u003E\u003Cbr \/\u003ELook for opportunities to combine your expertise in palliative care, your desire to help others do better and humility that you can always learn new ways to teach others tactfully.\u0026nbsp; My colleague recognizes this and has signed up for a \u003Ca href=\"http:\/\/www.vitaltalk.org\/courses\"\u003E\u003Ci\u003EVitalTalk\u003C\/i\u003E Faculty Development \u003C\/a\u003Ecourse this spring.\u0026nbsp; I've done this in the past and highly recommend it. \u0026nbsp;The facilitation methods are grounded in humility and curiosity. Also, keep your eyes out for the \u003Ca href=\"http:\/\/www.ariadnelabs.org\/programs\/serious-illness-care\/4\"\u003Ework being done by Gawande,\u003C\/a\u003E Susan Block, and others at Ariadne labs.\u0026nbsp; It's exciting stuff.\u003Cbr \/\u003E\u003Cbr \/\u003EI recently taught a communication course with a group of cardiology fellows using \u003Ca href=\"http:\/\/vitaltalk.org\/\"\u003E\u003Ci\u003EVitalTalk\u003C\/i\u003E\u003C\/a\u003E facilitation methods.\u0026nbsp; One of the very skilled fellows in my group came up to me a the end of the course yearning for even more feedback than what she received throughout the two day course.\u0026nbsp; \u003Cbr \/\u003E\u003Cbr \/\u003EAtul Gawande's eloquence may not be matched by many but he is not the only one who is humble and curious.\u0026nbsp; This brings me hope. \u0026nbsp; \u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003E\u003Cspan style=\"font-size: xx-small;\"\u003EHT to \u003Ca href=\"https:\/\/twitter.com\/plclary_clary\"\u003EPatrick Clary\u003C\/a\u003E for helping me get this quote right via his Tweet.\u0026nbsp;\u003C\/span\u003E\u003C\/i\u003E\u003Cbr \/\u003E\u003Cdiv\u003E\u003Ci\u003E\u003Cspan style=\"font-size: xx-small;\"\u003E\u003Cbr \/\u003E\u003C\/span\u003E\u003C\/i\u003E\u003C\/div\u003E\u003Cdiv\u003E\u003Ci\u003E\u003Cspan style=\"font-size: xx-small;\"\u003EPhoto: The 2014 PHS Philadelphia Flower show courtesy of www.visitphilly.com.\u0026nbsp;\u003C\/span\u003E\u003C\/i\u003E\u003Cbr \/\u003E\u003Cdiv style=\"text-align: left;\"\u003E\u003Ci\u003E\u003Cspan style=\"font-size: xx-small;\"\u003E\u003Cbr \/\u003E\u003C\/span\u003E\u003C\/i\u003E\u003C\/div\u003E\u003Cdiv style=\"text-align: left;\"\u003E\u003Ci\u003E\u003Cspan style=\"font-size: xx-small;\"\u003ELyle Fettig (\u003Ca href=\"https:\/\/twitter.com\/lfettig\"\u003E@lfettig\u003C\/a\u003E) is a palliative care doctor in Indianapolis where he lives with his wife and two boys, both who love \u003C\/span\u003E\u003C\/i\u003E\u003Ca href=\"http:\/\/www.imamuseum.org\/visit\/100acres\/artworks-projects\/funky-bones\"\u003E\u003Cspan style=\"font-size: xx-small;\"\u003EFunky Bones\u003C\/span\u003E\u003C\/a\u003E\u003Ci\u003E\u003Cspan style=\"font-size: xx-small;\"\u003E\u003Ca href=\"http:\/\/www.imamuseum.org\/visit\/100acres\/artworks-projects\/funky-bones\"\u003E at the IMA 100 Acre Park\u003C\/a\u003E. He proudly declares that he is a member of the VitalTalk Community which he considers an alignment of interests \u003C\/span\u003E\u003C\/i\u003E\u003Ci\u003E\u003Cspan style=\"font-size: xx-small;\"\u003Erather than a conflict\u003C\/span\u003E. \u003C\/i\u003E\u003C\/div\u003E\u003Ci\u003E\u003C\/i\u003E\u003C\/div\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/2851300209791806809"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/2851300209791806809"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2015\/03\/atul-gawandes-gifts-to-palliative-care.html","title":"Atul Gawande's Gifts to Palliative Care and Rethinking How to Teach with Tact"}],"author":[{"name":{"$t":"Lyle Fettig"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/00710388898582754749"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}]},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-2484687679920647475"},"published":{"$t":"2015-02-16T07:00:00.000-06:00"},"updated":{"$t":"2015-02-16T07:00:01.418-06:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"ethics\/law"},{"scheme":"http://www.blogger.com/atom/ns#","term":"fettig"}],"title":{"type":"text","$t":"Make the World a Little More Fair"},"content":{"type":"html","$t":"by Lyle Fettig, MD\u003Cbr \/\u003E\u003Cbr \/\u003EYou meet a 29 year old man with a history of Diffuse Large B-Cell Lymphoma.*\u0026nbsp; Palliative care was consulted after he presented to the hospital with lower extremity weakness and was found to have extensive new epidural spread of his disease as well as progression of disease in his chest and abdomen.\u0026nbsp; He was just diagnosed five months ago.\u0026nbsp; He started chemotherapy with hopes that he'd respond well enough for consideration of a stem cell transplant.\u0026nbsp; With documented progression of disease, it has become clear that would not happen.\u0026nbsp; \u003Cbr \/\u003E\u003Cbr \/\u003EHe'll die soon.\u0026nbsp; You look at him, his wife, and two year old daughter and wonder why.\u0026nbsp; The idiomatic thought springs forth naturally, \"What did he do to deserve this?\" even if you're consciously able to say \"this isn't his fault, he doesn't deserve any of this.\"\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"http:\/\/i1.trekearth.com\/photos\/136659\/justice.jpg\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" src=\"http:\/\/i1.trekearth.com\/photos\/136659\/justice.jpg\" height=\"320\" width=\"320\" \/\u003E\u003C\/a\u003EMaybe smoking is linked to lymphoma?\u0026nbsp; Maybe \u003Ca href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/15824165\"\u003Enot\u003C\/a\u003E.\u0026nbsp; And anyway, he never smoked. Even if he did, how many 30 year olds who smoke succumb to a similar fate?\u0026nbsp; A tiny percentage. He occasionally drank alcohol, but never did any other drugs.\u003Cbr \/\u003E\u003Cbr \/\u003EMaybe it's some other environmental exposure?\u0026nbsp; Maybe he was exposed to something at work?\u0026nbsp; He has worked at a facility that makes medical supplies.\u0026nbsp; Hmm.\u0026nbsp; No obviously known exposure risk.\u003Cbr \/\u003E\u003Cbr \/\u003EThere has to be something.\u003Cbr \/\u003E\u003Cbr \/\u003EWhat drives the desire for an explanation?\u0026nbsp; The answer to this question is complicated, but here's one factor that may drive the desire for many:\u003Cbr \/\u003E\u003Cbr \/\u003EThe \u003Ca href=\"http:\/\/penguinrandomhouse.ca\/hazlitt\/blog\/monstrous-cruelty-just-world\"\u003Ejust-world hypothesis\u003C\/a\u003E.\u003Cbr \/\u003E\u003Cbr \/\u003EPeople who strongly hold this hypothesis assume the world must be fair and may be more inclined to believe that if something bad happens to you, you must have deserved it somehow. This hypothesis \u003Ca href=\"http:\/\/www.theguardian.com\/lifeandstyle\/2011\/nov\/11\/oliver-burkeman-just-world-bias\"\u003Esees suffering and concludes that people who suffer must be the kind of people we disdain\u003C\/a\u003E.\u0026nbsp; If the world isn't fair, what bad things might happen to me? If unfairness like this exists, it's scary to confront. One way to avoid this fear is to assume fault of the person who is suffering.\u003Cbr \/\u003E\u003Cbr \/\u003EYou know the patient cannot be blamed for his lymphoma.\u0026nbsp; Maybe it can be explained by genetics, a quirk of cancer biology. But what about the 70 year old woman who has lung cancer after a 120 pack-year history of smoking cigarettes?\u0026nbsp; There's no doubt about the relationship between smoking and lung cancer.\u0026nbsp; The dangers of smoking \u003Ca href=\"http:\/\/www.npr.org\/blogs\/health\/2015\/02\/12\/385498822\/smokings-death-toll-may-be-higher-than-anyone-knew\"\u003Econtinue to be clarified\u003C\/a\u003E and every public health campaign that reduces smoking rates is a good thing.\u003Cbr \/\u003E\u003Cbr \/\u003EIs the non-smoking blamer reassuring himself about his own fate?\u0026nbsp; \"That couldn't happen to me- I have never smoked.\"\u0026nbsp; Tobacco contributed, no doubt. Can the blamer, armed with the just-world hypothesis, more easily \u003Ca href=\"http:\/\/www.cancer.org\/cancer\/news\/why-lung-cancer-strikes-nonsmokers\"\u003Eignore the fact that up to 24,000 people die in the United States from lung cancer every year without having smoked\u003C\/a\u003E? \u003Cbr \/\u003E\u003Cbr \/\u003EIn an unfair world, try not to blame the dying person or try to dispute the person's experience of unfairness.\u0026nbsp; The lifelong smoker may point to someone who lived twenty years longer while smoking.\u0026nbsp; It's true that smoking is bad, people should stop for their health, and still some people skate through in spite of it.\u0026nbsp; So it won't seem fair to many who don't.\u003Cbr \/\u003E\u003Cbr \/\u003EWatch out for this bias.\u0026nbsp; If you have feelings of blame (even if unspoken), examine what the source of those feelings might be for you.\u0026nbsp; Be gentle with yourself if you discover it might be in response to fear of an unfairness which is \u003Ca href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMp1410385\"\u003Euniversal in potentiality\u003C\/a\u003E.\u0026nbsp; Examine your own fears.\u0026nbsp; Don't let them obstruct a compassionate response to the experience of loss and grief which is a source of the patient's experience of unfairness.\u0026nbsp; \u003Cbr \/\u003E\u003Cbr \/\u003EAim to non-judgmentally provide safe passage and support to all until the end.\u0026nbsp; The world will be more fair as a result.\u003Cbr \/\u003E\u003Cbr \/\u003E*\u003Ci\u003EAny resemblance to real life patients is purely coincidental.\u003C\/i\u003E \u003Cbr \/\u003E\u003Ci\u003E\u003Cbr \/\u003E\u003C\/i\u003E\u003Ci\u003E\u003Cspan style=\"font-size: x-small;\"\u003EPhoto: Justice via Shutterstock\u003C\/span\u003E\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003E\u003Cspan style=\"font-size: x-small;\"\u003ELyle Fettig is a palliative care doctor in Indianapolis where he lives with his wife and two boys, both who love \u003C\/span\u003E\u003C\/i\u003E\u003Ca href=\"http:\/\/www.imamuseum.org\/visit\/100acres\/artworks-projects\/funky-bones\"\u003E\u003Cspan style=\"font-size: x-small;\"\u003EFunky Bones\u003C\/span\u003E\u003C\/a\u003E\u003Ci\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u003Ca href=\"http:\/\/www.imamuseum.org\/visit\/100acres\/artworks-projects\/funky-bones\"\u003E at the IMA 100 Acre Park\u003C\/a\u003E.\u0026nbsp; \u003C\/span\u003E\u003C\/i\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/2484687679920647475"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/2484687679920647475"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2015\/02\/make-world-little-more-fair.html","title":"Make the World a Little More Fair"}],"author":[{"name":{"$t":"Lyle Fettig"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/00710388898582754749"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}]}]}});