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Is Patient Engagement with Medicine different than World View?

Posted in Clinical & Translational, Cognition, Curation, Empathy, Fiction and medicine, tagged empathy, Garrod, Oslerism, patient engagement on November 23, 2015| Leave a Comment »

Is Patient Engagement with Medicine different than World View?

Curator: Larry H. Bernstein, MD, FCAP

In Mark Twain’s later years he had personal and financial losses. I think that was when he wrote “why do we laugh at a birth and cry at a funeral? It is because it is not I!”

The first Chairman of Medicine at John Hopkins Medical School was William Osler. He taught that a physician must be broadly knowledgeable about the arts and culture in order to make a difference in engaging the patient. This has come into play in the republican primaries for the first time, regardless of other requirements.

When I was a freshman medical student we had a special course on Inborn Errors of Metabolism. I think it was a first, given a new and energetic Chairman of Biochemistry from Harvard. Nevertheless, over the next decade, the influence of “Oslerism” was fading, to be replaced by the concept of a British physician, Archibald Garrod (1857–1936), in the early 20th century (1908). He is known for work that prefigured the “one gene-one enzyme” hypothesis, based on his studies on the nature and inheritance of alkaptonuria. His seminal text, Inborn Errors of Metabolism was published in 1923.[1] Some years later I learned that the selection of students entering was weighted in success with organic chemistry.

Type of inborn error	Incidence
Disease involving amino acids (e.g. PKU), organic acids, primary lactic acidosis, galactosemia, or a urea cycle disease	24 per 100 000 births^[3]	1 in 4,200^[3]
Lysosomal storage disease	8 per 100 000 births^[3]	1 in 12,500^[3]
Peroxisomal disorder	~3 to 4 per 100 000 of births^[3]	~1 in 30,000^[3]
Respiratory chain-based mitochondrial disease	~3 per 100 000 births^[3]	1 in 33,000^[3]
Glycogen storage disease	2.3 per 100 000 births^[3]	1 in 43,000^[3]

http://www.esp.org/books/garrod/inborn-errors/facsimile/
Jump up^ Vernon, Hilary (Jun 2015). “Inborn Errors of Metabolism: Advances in Diagnosis and Therapy”. JAMA Pediatrics.
^ Jump up to:^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l Applegarth DA, Toone JR, Lowry RB (January 2000). “Incidence of inborn errors of metabolism in British Columbia, 1969-1996”. Pediatrics 105 (1): e10. doi:10.1542/peds.105.1.e10. PMID 10617747.

When I entered my third year of medical school, I had a huge awakening. I was now engaged with patients at Detroit Receiving Hospital. It was not unlike Cook County, LA County, Charity Hospital, King County or Belleview Hospital. This was a year before the Detroit riots. Receiving Hospital (later Detroit General) had a large population of indigent patients and was a trauma center located adjacent to skid row. There were students who looked down on the patients, many on welfare, and who took a taxi to the hospital.
Most of my colleagues did not have that view. However, I would guess that my view was transcended some time later when I recall students concerned about “racial balancing” for entry to colleges.

I saw the victims of gun, knife and other violence in the Emergency Room (ER). On one occasion, the entire surgery staff was called out of the weekly Grand Rounds to attend to 3 cases with massive bleeding in the ER. One of the cases was presented the following week with a discussion of whether the patient should have been taken to the operating room instead of handling the emergent case in the ER.

I also recall a woman who might have been 45 years old who was extremely anxious and had had 5 divorces. Nobody came to visit her. We were taking her blood pressure when it spiked very high. My classmate might well have said holy smoke and ran to the library to check things out. She had a very rare occurrence of pheochromocytoma, a tumor of the adrenal medulla that secretes adrenaline. It was probably also a factor in her social history. It was the first such case to be seen by the Chairman of Surgery.

I don’t know that preparation in the great city hospitals has changed. It is an important experience. I did see some anger expressed by patients in the ER, mainly related to the life experiences of the patient. In my 20 years at Bridgeport Hospital, there was a large admission population from “Father Panic Village”. I recall vividly a patient saying to me, when he learned my last name is Bernstein, get away from me.

Over the years, not that much has changed. There is a much larger uneducated, unemployed, and ignorant population that has no hope of a future. It is most disconcerting at this time because they are bereft of a dream, and they don’t participate in our society. Moreover, large disparities influence voting patterns and also the use of tight public resources.

It would be difficult for me to consider this to be unrelated to an emerging world crisis that we are observing today. There is an increased downward pressure on the lower class with a vanished middle class. The entering well prepared medical staff is inundated, but more skilled at the inadequate medical information systems they have to use. There has been emigration to the UD for decades, but now we have more openly advocated do not come unless you have value to provide. We are in the midst of a Middle East crisis, and despite economic recovery since the Wall Street collapse, there is a “doomsday” chronicle. Emma Lazarus wrote “Give me your poor, … and your huddled masses yearning to be free”.

TS Elliott wrote “The Hollow Men” in 1925, post WWI . We remember “This is the way the world ends. This is the way the world ends. Not with a bang, but a whimper. I hope that it hasn’t come to that.