The intersection of physical and mental health

“Despair” (public domain art)

A good part of my medical practice at Hennepin Healthcare is in mental health.  Although I’m a general internist, meaning I specialize in chronic diseases of adults, I have a special interest in the intersection of medical and mental illness.  Consequently, I spend a hefty portion of my days on the inpatient psychiatry units.  So when a piece came out in the New York Times this week, I was immediately drawn to it.  Written by Dr. Dhruv Khullar from New York-Presbyterian Hospital, it is entitled The Largest Health Care Disparity We Don’t Talk About.  I strongly encourage you to read it.

This is particularly of interest to me since I have also been part of a group of five medical systems across the country who have recently published our own experience in caring for people with mental illness. You can read our very brief paper at the Annals of Internal Medicine.

In this post I’ll talk a bit about my own experience in caring for patients with mental health conditions.  I’ll end with a few suggestions. Continue reading “The intersection of physical and mental health”

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An introduction to acupuncture and chiropractic care

Medical school is four years long.  This is after four years of college.  It is then followed by three more years of intensive training during medical residency.  It’s a lot of learning.

So in all those years, do you know how much I learned about chiropractic care?  Just about nothing.  How about acupuncture?  Even less.  These are not disciplines that are taught in most US medical schools (at least the allopathic kind like I went to).

But research shows, and our day-to-day human experience probably confirms, that many people see chiropractors and acupuncturists for a variety of ailments.  In fact, many major medical systems, including my own at HCMC, offer a wide range of services to include chiropractic and acupuncture care.

To learn more about these disciplines, this past month on the Healthy Matters radio broadcast I invited two guests to help me out.  They were Robert Crane, an acupuncturist, and Peter Polski, a doctor of chiropractic care.  That’s the two of them in the WCCO studios during the live broadcast in the picture above.  Super nice guys, the both of ’em.

I encourage you to listen to the podcast of the show by clicking here –> Healthy Matters show #453, September 10, 2017.  Podcasts are great ways to listen, commercial-free, to the shows at your own pace.  Just download the show you want to your phone or computer and listen!

In this post, I won’t attempt to cover any of the specifics about chiropractic care or acupuncture.  They are disciplines to themselves and I couldn’t do either one justice in just a few paragraphs.  Rather, I’m going to give a bit of background on the two disciplines to give the neophytes among us a taste of what these practitioners can offer.  This is fairly new stuff to me as well as many of you, so I’m doing my best to learn something.  Read on, and more importantly, listen to the podcast! Continue reading “An introduction to acupuncture and chiropractic care”

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Maybe your doctor should be a woman

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Quick, picture in your head a highly competent physician.  What does that person look like?

Does your doctor image look like this?

Photo: ABC Television [Public domain], via Wikimedia Commons
Public domain photo

Or like this?

By Ministry of Information Photo Division Photographer, Stone Richard [Public domain], via Wikimedia Commons
Public domain photo

 For the record and the recognition, that’s Dr. Gibson-Hill, a doctor in Bristol, England.  You probably know the guy in the top photo.

History has maybe ingrained in us the image of doctors as many things, but first of all they have been men.  The reality, even dating back over a hundred years (Elizabeth Blackwell, anyone), is that women have served as physicians for a great long time.

And the reality today is that women are a huge part of the physician workforce in the United States.  I remember vividly one moment during the first hour of the first day of my Medical School education at the University of Minnesota some 20 years ago.  The Dean stood up in front of the nearly 200 of us eager young medical students and announced that for the first time in that school’s history, more than half the medical students were women.  The room erupted in applause that day.

My current practice bears this out.  In my group of hospitalist physicians at HCMC, we have 17 women and 14 men.  So when you see a doctor in our hospital and I presume at all other hospitals in the country, you are likely to be cared for by a physician who happens to be a woman.

This is a good thing. Continue reading “Maybe your doctor should be a woman”

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When Breath Becomes Air – Healthy Matters Book Club

when breath becomes air“I began to realize that coming in such close contact with my own mortality had changed both nothing and everything.”

Paul Kalanithi, from When Life Becomes Air

Welcome to Healthy Matters Book Club!  This is the first of what I hope will be many posts in which I will explore a health & medicine book that I have read and found interesting .  I’m not a book critic and this is not a thorough book review – just a couple of my thoughts.  I hope you will read it and join the conversation by leaving a comment below or perhaps joining me on Twitter @DrDavidHilden.  Plus, I’m hoping you will leave me book discussion suggestions in the comments – I’m always looking for a good read!

Today’s Book:  When Breath Becomes Air

Re-read the quote at the top of this post.  It is a pretty good summary of When Breath Becomes Air, the recent book from Dr. Paul Kalanithi.  I strongly recommend the book to you – it is a quick read – just a few hours – but it is gripping.

Dr. Kalanithi died in March 2015 and the book is a memoir of his last months of life.  An accomplished neurosurgeon and a rising star in the medical community, Paul Kalanithi learned of a terminal diagnosis when he was just 35 years old.   Also a talented writer who was initially torn between a career in medicine or as a writer, he set out to chronicle his life knowing that he would not live a great deal longer.  He is a terrific writer and his prose is quite lyrical – almost poetic to the degree that some may find a bit much –  and I found it brilliant.

Paul writes with an intimacy rarely seen in books by doctors.   Neurosurgeons, fairly or not, are not known for their sensitive sides.   But in this case, the surgeon becomes the patient and is faced with what he knows in his mind and in his gut – that he has a disease from which he will certainly die.  He knew it the instant he looked at his own CT scan.   This unnerved me a bit as I can imagine any of my colleagues facing the same situation in which we look at our own medical results and know a bit too much what it means for us.

When I was reading the book, I couldn’t escape the knowledge that the writer has already died and is really speaking from the grave.  Made me pause more than once or twice.

But it is a great read even if you are not a doctor.  Maybe even more so, as it gives you an unfiltered glimpse into the mind of a brain surgeon with a soft spot for poetry.  You really feel like you get to know him.  And just as great is that you get to meet Lucy, his wife, who seems to me an incredible person.

Throughout the reading I couldn’t escape the knowledge that Lucy and their infant daughter are still here – real people, alive and carrying on their lives.  To me Lucy is as fascinating as her husband and her epilogue is as poignant as her husband’s writing.  Now about one year after his death, she has found herself doing something she probably didn’t imagine just 2-3 years ago – she’s on a book tour for her late husband.

Here’s an interview she did on National Public Radio that I encourage you to listen to:

 “Live as if you were to die tomorrow. Learn as if you were to live forever.”

This oft-quoted bit of wisdom by Gandhi was realized by Dr. Kalanithi during his lifetime.  After his awful diagnosis, he continued to practice surgery, continued to read, continued to write, continued to love, continued to learn, and continued to reflect on what is important in life.  He indeed was acting as if he may well live forever.

But he also acted as if he may die tomorrow which for him was not an abstract concept but a real possibility.  One aspect of their lives that gets my thoughts all tied up in knots is their decision to have a baby, knowing that he would not live to see their child grow up.  Here is an exchange from the book:

“Will having a newborn distract from the time we have together?” she asked. “Don’t you think saying goodbye to your child will make your death more painful?”

“Wouldn’t it be great if it did?” I said. Lucy and I both felt that life wasn’t about avoiding suffering.”

Can you imagine having such a conversation when thinking about having a child? Holy cow.  Listen to the audio clip above to hear Lucy say more about this.

Join the discussion!

What would you do if you knew you had a very limited amount of time to live?  Would you continue to work at whatever you do?  Would you drop everything and try something new? What would you do if you were Lucy – his spouse?  Are you a “live-for-the-moment” type or a “planner for the future” type?  Maybe a little of both?

So now it’s your turn.  Read the book and leave a comment below with your reactions.  I’d love to hear your thoughts!

Also, if you have read a health/wellness/medical book that you’d like to recommend – leave me a comment right here on the blog (in the comments section below).   Can be fiction or non-fiction.  Maybe we can discuss it on a future post on the Healthy Matters Book Club!

 

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Reflections on bias in health care

Do black people feel less pain than white people?  Are overweight people at fault for developing diabetes?  Do doctors evaluate symptoms differently if a white man reports them than if a black woman reports themrace bias nejm?

Most of us would emphatically answer these no, no, and no.  But there is evidence that the answers actually are much more complex than that.  For instance, there is scientific data that suggests that people hold unacknowledged attitudes that African-Americans feel pain less than white people.  Some people do feel that overweight people are personally to blame for their diabetes.  And there are studies that suggest that doctors evaluate and treat people differently based on race.  (The punch line of the study is that when the actors in this picture reported symptoms to doctors, they received different treatment recommendations despite identical symptoms – a fascinating study).

I think these are disturbing but important things to think about if we are going to address disparities in health care.

This post is prompted by a class that I facilitated at the University of Minnesota Medical School.  I was pinch-hitting for a colleague this week in a small-group discussion class that that aims to get these first-year medical students to think about something other than biochemistry and physiology.  Stuff like bioethics, humanistic care, doctor-patient relationship, and so forth.  There were ten of us seated around a table discussing the week’s topic – bias in medical care.  (As an aside – if these 10 thoughtful students are any indication – the future of health care is in good hands.)

I’d like to share some reflections from that session and offer some interactive resources for you to try – the exact same ones the students did.  And you don’t have to pay medical school tuition!  So read on, think about it, check out some of the links, examine your own biases, and leave a comment on this blog post. Let’s talk about it.

(At the bottom there is a link to a thought-provoking self-assessment that you may wish to consider doing yourself).

Being privileged

I think the first step toward addressing bias is to examine our own situation.  Here is my situation, in the proverbial nutshell:

  • White
  • Male
  • Straight
  • Financially secure
  • Naturally-born United States citizen
  • Protestant Christian
  • English-speaker
  • Not overweight

I don’t apologize for any of them – I am happy with who I am.  But it is crucial to realize that I didn’t do anything to accomplish any of those things – and yet, my personal characteristics put me in a place of privilege.  Nobody would doubt me if I showed up in an Emergency Department with chest pain.  I’d get the appropriate tests in an instant and probably be provided with pain medications without delay.

Would I get the same great medical care if I were a disheveled homeless man?  If I didn’t speak English?  If I were a Muslim woman wearing a hijab?  If I were a transgender person?  If I were a woman?  If I were overweight?  Maybe, maybe not.

So we talked about this with the medical students, starting with recognizing one’s own privilege and naming it out loud.  I told the students, especially the white guys, that it is totally OK and cool to be a white guy.  No apologies.  But it is important to recognize the privilege that comes with personal characteristics which you were simply born into.

Great quote:  “When you find yourself on 3rd base, don’t assume you hit a triple to get there.”

Unconscious bias vs. conscious bias

What is bias, anyway?   The medical students in our class watched the following video of a talk given by a physician who reflects on his own bias.  It is worth 15 minutes of your time:

This video raises several points to ponder, but two stick out for me.  First, Dr. Attia painfully recalls the contempt for which he held a diabetic patient – basically blaming her for needing a leg amputation because she was – as he recalls – “fat” and therefore somehow responsible for her decaying leg.  Years later he still feels the need for her forgiveness for this attitude that he wasn’t even aware of at the time (be sure to watch it to the end).  The second point is his recognition that medical science may, in fact, not always be accurate.  This second point is certainly true and something I hope to explore in future posts.  The first point is a perfect example of bias.

In our medical school discussion, we tried to acknowledge the possibility that we could be harboring bias even without knowing it – implicit or unconscious bias as opposed to  explicit or conscious bias.

Explicit bias

First the one that is easy to identify – explicit bias.  This is something we deliberately think about and often verbalize.  Consider the current United States presidential campaign, when serious candidates for the presidency are endlessly providing examples of explicit bias:  accusing whole groups of people of nefarious deeds (Mexican people as rapists), labeling hundreds of millions of people into stereotypical categories (lumping all Muslims together), openly advocating mass killing of innocent people for being not like us (“carpet-bombing” whole populations of civilians).

These are open, deliberate attitudes that should be easy to identify and weed out (although sadly we often fail at this).  I would call them explicit biases and we should reject them outright.

Now the harder one.  Contrast explicit bias to implicit (or unconscious) bias.  These are the attitudes that we are not conscious of and that we may well deny holding when confronted with them.  But they are real.  Like Peter Attia in the Ted talk (click picture above if you missed it), I would never openly accuse a person with diabetes of being personally responsible for her gangrenous leg.  But deep inside me, would a part of me wonder if she could have tried harder to lose weight?  If she had only cared for her leg a little better could she have avoided an amputation?  I think that it is not only possible that I could hold such unconscious biases, I think it likely that I do.  And most of my physician colleagues do as well.

This part is hard  . . . examining our own bias

The medical students were asked to take a self-assessment, called an IAT (Implicit Association Test).  My first reaction is that the IAT is just another bit of academic jargon, but having tried it I found it actually sort of cool.  The test involves words and images appearing on the screen, and the students are asked to rapidly react to the images by making a selection.  No thinking about it logically.  Just react.

I encourage you to try an IAT – take a test yourself.  This can be difficult emotionally, so prepare yourself.  Hearing your own results may not be easy but it is eye-opening.  Before you take a test, read the materials from the Implicit project (a consortium of researchers) on the website and then take the test yourself.  Note that the interpretation of your results may be troubling to you.  With that in mind – give it a try.

Did you discover any unconscious bias in yourself?  How did it make you feel to hear that you may harbor attitudes that you were not aware of?  Do you agree that such biases exist in you?  And if so, what ought we to do with that information?  How is our society affected, not only in healthcare, but in other aspects of our life, when such biases exist?  Does bias contribute to unequal health care outcomes? 

This is a conversation worth having.  Tell me what you think – leave me a comment!

 

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