Running with my patient

Running with my patient

G Model PEC-4761; No. of Pages 3 Patient Education and Counseling xxx (2014) xxx–xxx Contents lists available at ScienceDirect Patient Education an...

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G Model

PEC-4761; No. of Pages 3 Patient Education and Counseling xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou

Reflective Practice

Running with my patient§ Ohad Avny *, Aya Alon Clalit Health Services Hebrew University, Hadssah Faculty of Medicine, Jerusalem, Israel

A R T I C L E I N F O

Article history: Received 16 September 2013 Received in revised form 17 March 2014 Accepted 25 March 2014 Keywords: Physical exercise Diabetes Life style modification Relationship

I remember my first encounter with Joshua, a patient who was diagnosed a few years earlier with diabetes when hospitalized for tonsillitis. Joshua’s father suffered from diabetes and the various complications of this disease. He died in his 50s while on dialysis. I am currently at the age my mother was when she died at age 49, thirty years ago. My father died suddenly in his late 60s, five years ago, just as I was at the height of my ever-so sedentary lifestyle. After his death, I underwent a thorough medical examination, including an echocardiography, a Holter monitor and a stress test which were all within the normal limits. I was suffering from a ‘‘high-normal’’ blood pressure, impaired fasting glucose (IFG) and my obstructive sleep apnea was worsening. My Body Mass Index (BMI) was 30, my lipid profile did not look good: LDL = 180, HDL = 35; and my triglycerides were ‘‘sky high’’. In short, I was a typical case of metabolic syndrome, the same syndrome that may have contributed to my father’s death. There we sat, on either side of the desk, one with diabetes and one with a metabolic syndrome, both of us threatened by our family history. I had an inner conviction that something drastic must be done in both our lives to avert a similar fate as that of our parents. At the time, Joshua was at a professional crossroads, after leaving his various business ventures. I too felt at a personal and professional crossroads. I had recently returned from a fellowship

§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–253. * Tel.: +972 2 506260240; fax: +972 2 6518778. E-mail address: [email protected]

in geriatrics in Canada and was contemplating whether I should devote myself entirely to geriatrics and palliative care, or continue with family practice. How, I asked myself, does one go about making a meaningful change in one’s life? I thought that perhaps the medical and spiritual issues I was wrestling with mirrored the ones Joshua was contending with. As an experienced family doctor I have learned the importance of relating to my patient’s inner emotional world, and I’m often able to create positive alliances with even the most difficult patients. The walls of my office are adorned with drawings made by my three daughters as well as by family photographs. At first they were placed there to make me feel at home. In time, I learned that they often served as ‘‘ice-breakers’’ with many of my clients who inquired about my personal life and then shared theirs, creating a less hierarchic atmosphere. Over time I found that those who chose to address the drawings tended to feel more comfortable with a less formal communication style, while those who chose not to mention them were more comfortable with a rather formal approach. Thus, these drawings are in a way an invitation for my patients to choose their mode of communication with me as their physician, and I follow their lead. Joshua is a short and thin man, whereas I am tall and overweight. We are about the same age and come from a similar cultural and socio-economic background. Joshua studied business management and worked on various projects. He never married. Joshua did not respond to my usual ‘‘ice-breaking’’ techniques that enable me to create easy connections with people and never revealed anything personal about himself. To this day I do not know much about his inner world. In hindsight, Joshua taught me a lot about how there is no ‘‘onesize-fits-all’’ method for creating connections. Working in a public health clinic setting is challenging in that I have just a few minutes to discuss such a wide range of problems with each patient, while my mind still lingers on previous patients and is already concerned about those to come. Joshua taught me about the need to be creative in order to reach him. My sincere interest in him and my communication skills were simply not enough. The breakthrough occurred when Joshua began treating his diabetes through physical exercise. He adamantly refused medical treatment despite his hemoglobin A1C level of 9%, microalbuminuria and retinopathy. He preferred the route of alternative medicine. I was already making changes in my lifestyle, but my encounter with Joshua and with the positive effect of physical exercise on his diabetes definitely encouraged my own process. I shared with him my recent experiences in changing my own lifestyle as well as

http://dx.doi.org/10.1016/j.pec.2014.03.021 0738-3991/Crown Copyright ß 2014 Published by Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: Avny OM. Running with my patient. Patient Educ Couns (2014), http://dx.doi.org/10.1016/ j.pec.2014.03.021

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my concerns about my metabolic syndrome which may have been one of the causes of my father’s untimely death. I have often found that saying more rather than less about myself has helped develop a healing relationship within which my patients can make positive choices about their medical condition. I sense it is important for patients to feel the physician’s own humanity. This was the case with Joshua as well, where this was expressed through sharing our athletic experiences. However, I believe the subtext also included a hidden competition between us which at some point I became aware of, but continued to foster, for I felt it encouraged both of us to continue our involvement in sports. I have never been one to enjoy competition, but there was something about my relationship with Joshua that stirred me into action. I began working out regularly and slowly but surely increased the intensity and frequency of my physical exercise and began losing weight. Due to my previous experience in physical exercise and the sports injuries I sustained I could help Joshua diagnose and treat his runner’s knee and plantar fasciitis. Thus, together, we overcame the challenges and pain that persistent physical exercise can pose. Joshua slowly reduced his HGA1C level to 6.5% and to my surprise agreed to begin treatment with ACE inhibitors and metformin. I was impressed and thrilled by the changes he made and how he succeeded in altering both his lifestyle and perspective, as reflected in his willingness to take medication despite his obstinate resistance and fear of such interventions. Perhaps my acceptance of him on his own terms enabled him to accept something allopathic as well. Joshua became a long-distance runner and sports became an integral part of his life. To my great joy, I also incorporated physical exercise as a regular part of my life and I recently participated in the Jerusalem mini-marathon. At the 18th kilometer I felt a light tap on my shoulder. I grudgingly turned my head (I was totally exhausted at this point already), and there was Joshua: ‘‘How are you?’’ he asked. ‘‘I’m dying here’’ I managed to reply. ‘‘Well done!’’ he replied, and then continued: ‘‘This time I’m running the full marathon – this is my 32nd kilometer and I feel great’’. At that moment, despite my utter exhaustion, my competitive spirit arose and I did all I could to catch up with him, but I quickly surrendered. I was simply not strong enough. Joshua whizzed onwards, disappearing ahead. In reflecting on my relationship with Joshua, I realized that as long as our relationship was based only on the conventional hierarchical doctor-patient model, nothing moved in the treatment. The moment we became a couple of forty-some-year-old men obsessively involved in competitive sports, closeness emerged between us that I believe enabled us both to change. I noticed that when discussing our sports activities he would suddenly call me by my first name, whereas when returning to discuss his diabetes he would once again address me as Dr. Avny. It seemed he was setting the boundaries which changed according to his needs – at times he needed me as a companion and at other times he needed me as his physician. I learned to adapt to his changing needs, which taught me about the need for flexibility and complexity, and again, how there is no one-size-fits-all answer – not even for the same patient. In addition to enhancing my listening skills as a physician, Joshua also unknowingly served as a catalyst for my own personal growth and healing. The competition served as a positive catalyst for me, teaching me that competition is not necessarily something to avoid and can actually be a positive force of growth. I am reminded of the archetype of the wounded healer, the phrase used by psychologist Carl Jung to describe experiences in the relationship between analyst and patient, where the analyst

examines himself and is willing to experience his own vulnerability and pain in order to probe, understand, and heal the pain of their patient [1]. The archetype of the wounded healer teaches us that the healer is inseparable from the wounded human being, while the function of the wound is to let the healer know that he too needs to be healed. It is only by being willing to face, consciously experience, and go through our wound do we receive its blessing. Facing Joshua helped me face my own fear of illness and death, shaking me into the awareness that I was dangerously treading down my father’s path. And so, when treating Joshua, I subconsciously was healing myself. Our similar challenge enabled a positive healing relationship to develop and after years of futile experiences in ‘controlling’ Joshua’s diabetes and my metabolic syndrome we both managed to change our lifestyles and treat our diseases. When caring for Joshua I was also caring for myself. His progress inspired me and he became a role model for me. I was so surprised that it was this hard-to-reach patient with whom I previously did not feel any real intimacy that had such a significant role in my health and helped me treat my weight problem and alter my lifestyle. Perhaps it was a sense of shared fate in the shadow of our haunting genetic backgrounds that created the sense of brotherhood I experienced that set the process of change in motion in my life. I never spoke to Joshua directly about his contribution to my health and my sense of shared destiny with him, though these thoughts were clearly in my mind. I believe my own healing process was not of much interest to him and respected what I guessed was his indirect request to keep our relationship formal concerning medical issues. Perhaps it was the unspoken that powerfully bound us together, reflecting the unspoken words between our fathers and ourselves, their silent call beckoning us, inspiring us to change while we can. And maybe, just maybe, we both simply needed someone to run with. A note on self-disclosure As a physician who is always seeking evidence, I sought information on physician self-disclosure when writing this narrative. I found a wealth of information, indicating selfdisclosure within a professional medical relationship is a notoriously controversial topic. Some studies reveal that primary care physicians are talking about themselves to 25–30% of their patients, and that these disclosures may not be effective in increasing rapport, conveying understanding or improving selfcare [2–4]. However, my experience matches the finding whereby experienced family physicians report that use of self-disclosure can promote intimacy and mutuality [5]. Yalom [6] also insists on the need for a ‘‘human encounter’’ in order to help his patients and writes: ‘‘I have never had the experience of disclosing too much. On the contrary, I have always facilitated therapy when I have shared some facet of myself’’. When reflecting on my relationship with Joshua, I would like to think my self-disclosure may have also contributed to Joshua’s health. Perhaps I also served as a role model for him, which is noted as a potentially good reason for physician self-disclosure [7]. At the same time, my decision to refrain from sharing this narrative with him was perhaps my way of not burdening him with excessive selfdisclosure, thus maintaining the guideline of keeping disclosures brief and directly related to patient concerns so as to remain effective [2–4]. This meant I could never quite ascertain his own view on his healing process and the role of our relationship in facilitating this process; thus, my narrative here is entirely my own interpretation.

Please cite this article in press as: Avny OM. Running with my patient. Patient Educ Couns (2014), http://dx.doi.org/10.1016/ j.pec.2014.03.021

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References [1] Jung CG. Fundamental questions of psychotherapy. In: Read H, Fordham M, Adler G, editors, The practice of psychotherapy: essays on the psychology of the transference and other subjects [Hull RFC, Transl.]. Princeton: Princeton University Press; 1981. p. 111–25 [Collected Works of C.G. Jung 16 (1929)]. [2] McDaniel SH, Beckman HB, Morse DS, Silberman J, Seaburn DB, Epstein RM. Physician self-disclosure in primary care visits: enough about you, what about me? Arch Intern Med 2007;167:1321–6. [3] Beach MC, Roter D, Rubin H, Frankel R, Levison W, Ford DE. Is physician self-disclosure related to patient evaluation of office visits? J Gen Intern Med 2004;19:905–10.

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[4] Beach MC, Roter D, Larson S, Levinson W, Ford DE, Frankel R. What do physicians tell patients about themselves? A qualitative analysis of physician self-disclosure. J Gen Intern Med 2004;19:911–6. [5] Candib LM. What doctors tell about themselves to patients: implications for intimacy and reciprocity in the relationship. Fam Med 1987;19: 23–30. [6] Yalom I. The gift of therapy. New York: HarperCollins Publishers; 2002. [7] Morse DS, McDaniel SH, Candib LM, Beach MC. Enough about me, let’s get back to you: Physician self-disclosure during primary care encounters. Ann Intern Med 2008;149:835–7.

Please cite this article in press as: Avny OM. Running with my patient. Patient Educ Couns (2014), http://dx.doi.org/10.1016/ j.pec.2014.03.021