Archive for März, 2015

Being Mortal – by Atul Gawande

1. What is your understanding of the situation and its potential outcomes?

2. What are your hopes and what are your fears?

3. What are the trade-offs you are willing to make and not willing to make?

4. What is the course of action that best serves this understanding?

photo (72)With these questions Dr Atul Gawande describes in his book Being Mortal how doctors and families can help patients and loved ones in their decision making and help to achieve realistic and wanted goals. Not only in illness but also in the often underestimated process of growing old and planning elderly care.

Being Mortal struck me instantly on many notes. It struck me firstly as being a book that I could have written myself. Because it speaks so many truths that I have seen in my day to day medical life. It struck me because Gawande is a surgeon, and surgeons are supposed to be arrogant, drive fancy cars, flirt with nurses and be far less interested in what happens to their patients outside of the operating theatre. And it struck me because with the 4 questions above, it seems like a clearer text may be possible in many of the difficult situations and decisions that patients routinely face.

Gawande uses not only examples from his medical career, but also personal examples of his own father and his wife’s grandmother. Thus, it is far from just a doctor preaching about his insights into the world. It is just as much the story of a son and of a husband dealing with the issues which at some point will touch every family.

Not long ago, a nurse on our ward stated that she felt that we were not making any of our patients better, and for that reason, she found it harder and harder to work there. This initially sounded more than a little esoteric to me. Sure, we deal with a lot of chronic lung diseases, which are at times sadly and frustratingly incurable and progressive. In many cases, this comes with an extremely poor prognosis and inevitably a death caused by the disease.

But on the ward, we were making lung cancers smaller (even if only for a limited period) with our treatment, treating episodes of infection and making breathlessness manageable enough to enable a discharge home. Didn’t that count as making people better?

Quite often, yes. But in many of the more gruelling cases, I wonder retrospectively if our patients achieved their goals and realised the price they were paying for it.

Hospitals are however taking steps to acknowledge this. In my current hospital, we are lucky enough to work closely with a clinical psychologist, because we realise just what an impact physical illness (particularly chronic disease) has on metal health. Social workers are equally crucial in the team.

In my previous hospital, we tried out a so-called ‚Wegbegleiter‘ or sort of a hospital companion: a doctor who was there most afternoons to spend time talking to patients and their families, accompanying them through their hospital stay, discussing their hopes and fears, liaising with the nursing and medical team, without being in any way responsible for their medical treatment. A ‚medical middle-man‘ who has the time to explore issues which are invariably not part of the daily ward round. It was a huge success. It improved patient satisfaction and it made the life of the physician in charge notably easier.

As Gawande point out, medicine in many parts of the world has gone beyond simply the prolongation of life. It is just as much about maintaining a quality of life which is deemed to be acceptable. When I get back to work, I will definitely keep in mind the 4 questions above and be better prepared to tackle the difficult but crucial conversations that doctors and patients sometimes fail to have.

Music therapy: singing as a medicine

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Music is something which accompanies all of us through life: a way of expressing happiness, indispensable at times of sadness when words alone seem too feeble or simply too difficult to bear, for melancholic evenings at home so we are never alone or empty, a source of fun to be shared with friends, to mark all festive occasions.

Music can also accompany illness. I’ve always been vaguely aware of the existence of music therapy. But despite my interest in all things musical, it’s not something which I have encountered in my medical life so far, so that I conclude that it is far from a routine offer in conventional adult medical practice.

The weekly medical magazine in Germany – Deutsches Ärzteblatt – reports this week about the healing power of song. Studies have shown that singers in a choir not only feel better and more relaxed subjectively, but that they have a measurably increased production of the feel-good hormone oxytocin and of immunoglobulin A as well as a reduction in the level of the stress hormone cortisol.

The positive effect of a choir practice at the end of a long day at work is something I have never failed to feel.

But singing can be used to help the sick. It has been shown that the anxiousness, fear and pain in patients suffering from cancer can be reduced through singing.  In Germany, there is even an ‚Association of singing hospitals‘, where musical therapy specialists lead singing groups for patients and where research in the field takes place. Some 23 hospitals in Germany claim the title. That’s not very many, given the size of the country, and probably explains why I have never come across something like it in my everyday life. But something which appears to be growing.

The article reminded me of a member of my old choir who was diagnosed with a metastatic recurrence of her breast cancer many years after her initial therapy. On the week I telephoned to enquire how she was feeling before the results (waiting for results is often the worst time of all), which I knew from the scans looked bad, she told me above all about the choir practice she had attended and about the next choir project she was looking forward to. Perhaps she had her priorities right.

Living a life with an illness can be a difficult thing. But if music is indeed in some small way a healer, then let it play on.

A few days in Venice

Everybody seems to have advice for expecting parents. And I’m not averse to listening to it. It mainly seems to centre around get as much sleep as you can (which is not as easy as said with an increasingly uncomfortable belly), relax, go to the cinema lots (done pretty well on this one) and enjoy the time together before your relationship changes in an indescribable way, forever.

A weekend aways exploring a new city seemed like the perfect thing to do. And we couldn’t have picked a better place than Venice for our last trip away together as a couple.

A city so different from any I have ever seen, drenched in wistful romance and encumbered with so many bridges and steps that the idea of going there with a small child just seems silly. And what do you know it? A 6.5 hour train journey from Munich.

Being an early riser, I was rewarded with this wonderfully warm, springtime light on our first morning.

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The city is perfect for aimless wandering. Every second turn seemed to lead onto a lively square with the next bar ready to serve you an espresso in the sun.

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The mixture of fully renovated facades mixed with more run-down buildings, added charm and made it feel less like a full-blown disney land. The vaguely present images in my head of Canaletto’s Venice were however not disappointed.

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DSCF4083And the sight of Gondoliers in their wonderful costumes was to me, fitting rather than kitschy.

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Watching the sunset whilst sitting along one of the city’s many promenades, revelling in that glorious light….that’s something which will surely stand us in good stead for the chaotic weeks and months ahead.

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How to feed babies at risk of nut allergies

Those suffering with an allergy are never truly understood by people without them, with their allergies often being taken less seriously than they should. My sister-in-law has a nut allergy.  On one occasion, her post-nights husband breakfasted unthinkingly on crunchy nut cornflakes before driving home to kiss his wife. The traces of nuts were enough to set off an impressive facial swelling. And it was finally clear to the nut-loving family that she had married into, just what having a nut allergy means.

The recent editorial in the New England Journal of Medicine reported what can be viewed as breaking news in the world of allergy. To date, parents with multiple allergies were told to avoid feeding their children – particularly in the first year of life – with highly allergenic foods (such as peanuts, milk, egg, tree nuts) in order to reduce the likelihood of them developing allergies. Following observations to the contrary, a controlled trial was started to test this hypothesis. Specifically, peanut allergy – being one of the commonest food allergies and also potential one of the most life-threatening –  was studied. The results were published this week.

Over 500 children at high of a peanut allergy (for example those with eczema or milk allergy) were randomly assigned to either receive peanuts in their diet on a regular basis or to receive a peanut-free diet. Before enrollment, the infant were checked with skin pick tests, to rule out a severe sensitization against peanuts. At 5 years of age, the children were given a peanut challenge to determine the prevalence of peanut allergy. The prevalence of peanut allergy in the group avoiding peanuts was 17.2% as compared with 3.2% in those who consumed peanuts 3 times a week over a period of 5 years.

The clarity of the results suggests that guidelines are likely to be changed in the future and will hopefully lead to a fall in the currently rising levels of peanut allergy. And it will be interesting to see what the implications are for other food allergies.

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