Monday, June 29, 2009

Magical Thinking

Zusne and Jones (1989: 13) define magical thinking as the belief that that one's thought, words, or actions can achieve specific physical effects in a manner not governed by the principles of ordinary transmission of energy or information.

When I went to medical school, we were taught that magical thinking was either a harmless superstition like crossing one's fingers to bring them luck, or a dangerous psychotic delusion, like stepping off a ledge and expecting that you are going to fly.

Since school, I have observed (and frankly participated in) varying degrees of magical thinking. Some lines of thought are fun and some are scary but all have at their core the fervent hope that things will be different than what they are for real.

Since my "evolution" as a physician I have been able to observe that the most ardent practitioners of magical thinking are those of us in the medical profession. It is common practice, for instance, when performing minor procedures at the bedside to disinfect an area of the skin three times prior to performing the procedure. There is no evidence to prove this, but it is commonly done... so much so that the little packets of iodine swabs used for skin disinfection have three little pre-saturated swabs.

Much of this has come down to us from the middle ages mixed with the very real concerns for public health and the provable infection control practices of modern medicine... but still curious.

Unfortunately there are two common threads of magical thinking out there that are perpetuated by the health care community.

The first one is that medicine and medicines can cure anything from cuts and bruises to severe depression. Like any good magical thought, it has it's basis the provable facts of cure from many diseases, however medicine cannot cure many of the ills associated with life itself, such as aging, self abuse such as smoking and obesity. These require the more tedious and "obnoxious" change in lifestyle.

The second (and infinitely more cruel) form of magical thinking is perpetuated by the fears and hopes of medical practitioners themselves. When a person is found to have a terminal illness of any kind (cancer, heart disease, lung disease, etc...) rarely is this information related to the patient. The severity and need for frank and honest discussion of the very real prognosis is held back in the "magical thought" of not wanting to take away hope. Often the thoughts of the practitioner and the thoughts of the family and patient become so intertwined that they begin to exist in each other's fantasy of cure, instead of the reality of treatment and hope for a good life for as long as it lasts.

I am a deeply religious man and I believe strongly in prayer and the power of hope. I have seen in my life what I perceive as being true miracles. However I have seen these miracles happen in the face of a patient that realizes that these are indeed miracles, that these cures and recoveries are the products of a higher power and not the result of crossing our fingers and rubbing our rabbit's foot for luck.

Thursday, June 25, 2009

"Pal Care" and Shoeboxes

Recently, my team and I were sitting and talking with a patient who was hospitalized due to severe pain from multiple myeloma. On her admission, this lovely vivacious woman was reduced to a cringing shell, praying for death.
Fortunately, we were able to positively affect her symptoms and she became much more talkative and showed us a spunky, flirtacious woman who has more life than three normal people combined.
She has labelled our team "Pal care" and I asked her if it was really that hard to say the word palliative? She laughed and said... "No silly, you guys are my pals, so you guys are Pal care".
What a great idea and one which caught us all aback, yes indeed we try to be the patient's Pal.
This lovely woman also explained to us that we now have a Pal Care shoebox.
When asked to explain, she said that everyone has a shoebox, the oncologists live in the cancer shoebox, her fears live in the stinky thoughts shoebox, and now we are in the Pal care shoebox. I cannot think of a better description of "compartmentalization".
Today, as she was preparing to leave tomorrow morning, she asked me to stay behind and speak privately to her after the team left the room.
She spoke to me of her fears... fears of death... fears of a life of pain... and fears of saying goodbye to the hospital family she has grown to love, even without knowing their names.
As I left, she touched my hand and said, "thank you for helping me deal with the stinky thoughts shoebox".

Sunday, June 14, 2009


As of this writing, I am on the eve of removing the ventilator support for one of my favorite patients in the world. I have known her for over 15 years and she is one of the few remaining patients that I continue to see from my pre-palliative care internal medicine practice. She has severe Adult Respiratory Distress Syndrome due to sepsis and pneumonia and she is near death already on multiple pressors and full support.
In her terminal episode, she has taught me many things.
Once again I was reminded that I cannot fix everything, no matter how hard I tried.
I found myself tearful as I ordered her intubated... a chill running through me and an unspoken cry of "Oh my God this can't be happening" in my gut.
I found that I had to let go... I had to let another physician - an intensivist - take over her primary care (difficult because I am a trained intensivist), because I am definitely "too close".
And I found myself today sitting with her son in her isolation room in the ICU... two grown men talking about the end of a lovely woman's life, while we were wearing green isolation gowns, yellow masks, latex free gloves, and "poofy" blue bonnets.
In one instant tears became laughter as I visualized us both in those ridiculous outfits and I shared it with her son.
He laughed... and said that in the end... his Mom would have been hysterical laughing at us both.

Wednesday, June 10, 2009

Dealing with the loss... when death is no where to be seen.

The loss of a loved one is never easy. 
It never seems right nor fair.  
However when death follows a long arduous trial by a disease such as cancer, emphysema, heart disease, or kidney disease... it seems almost a welcome end to the suffering, an end to the pain.
Similarly, when death follows from a massive trauma in which our loved one is maimed and disfigured... death brings relief and the knowledge that no indignity will further disfigure the beauty of our loved one.
But what happens when death is rapid, and yet nowhere to be seen?
What happens when our mother, father, brother, sister, cousin, uncle or other relative lays in the bed on a ventilator... pristine and beautiful, body untouched by the ravages of disease nor the disfigurement of injury?
Recently I cared for two patients, a young man and a young woman who both suffered hypoxic encephalopathy... no trauma marred their bodies... no disease ravaged their lives... the circumstances where at once rapid and fatal, but through our technology, we were able to restore cardiac function.
It fell to me to explain to the family of each of these patients that your son... that your mother... who looks so beautiful and pristine save for the tube coming out of her mouth, is dead.
No shadow over her bed. 
No scars to make his death heroic.
No epic story to make us rejoice at the release of death.
Just two perfect bodies, devoid of the "person" who used to inhabit them, laying in the bed.
And two beautiful families dealing with death... when death is nowhere to be seen.