GrandRounds is up at Parallel Universes

A very interesting collection. Please have a look at Parallel Universes. I am honored that my post is among his top 5 picks.

TheTragedy of Self Immolation

Sometimes you stumble upon something and it makes you realize, no matter what your suffering is, how privileged you are.

The May 22 issue of the New England Journal of Medicine had an article that stopped my heart cold. It is entitled, Driven to a Fiery Death - The Tragedy of Self-Immolation in Afghanistan.

It begins with these tragic statistics:

"Afghanistan, a country with 32 million residents, has been engaged in constant conflict for the past 30 years. This instability and insecurity have resulted in a stark economic climate and a very low life expectancy. More than half of the people in Afghanistan live in poverty, and 40% of the adult labor force is unemployed. Life expectancy is 44 years, and annual mortality is 20 per 1000 residents."

Against this backdrop of destitution, the authors superimpose a horrendous tragedy.

"70 to 80% of female Afghanis are forced into marriages, and 57% are married before 16 years of age; 84% of women are illiterate as compared with 69% of men, and women are half as likely as men to have completed primary school. Afghan women have a fertility rate of 7.5 births per mother, and with a skilled birth attendant present at only 14% of births, the country's maternal mortality is the second highest in the world."

These facts, however, do not represent the worst tragedy. That is yet to be described.

"The Afghanistan Independent Human Rights Commission and the Afghan Ministry of Women's Affairs report the identification of 106 cases of self-immolation (by women) , in 2006; if these events are considered instances of violence against women, they account for 5 to 6% of all such violence reported that year."

"Self-immolation is the act of burning oneself as a means of suicide."


Half of these cases were women between the ages 16 to 19. This is a picture of a young burn victim. The gauze over her face is used to keep flies off.



"Often, self-immolation was said to have occurred after victims spoke out against or sought help in alleviating the violence to which they were subjected — but were ignored." Violence perpetrated by husbands, in-laws, and husbands' other wives.

To burn yourself, because it must be a lesser torture than those to which you are subjected every day by your husband, by your family; to disfigure yourself as testimony against those who have savaged you; to seek release in death not through the quietness of a knife but through the explosiveness of fire -- it stops my heart. I don't know what to do.....

Is donating money to groups on the ground, working for women's rights in Afghanistan enough? No...but it's a start.

Sheila & Harry: A Story about an Under-Functioning/ Over-Functioning Couple

Over the past several years, Sheila, age 80, has been the designated patient. Her closest friends are her doctors whom she believes understand her best. In any given week, she may have two to four appointments. She takes a jumble of medications, some of which are not compatible with each other, and intermingling them can cause the symptoms they are intended to alleviate. As the months go by, she spends more and more time on the couch.

Lately, a new dynamic seems to be setting down roots. Her husband, Harry, age 82, has had several serious falls which resulted in hospitalizations followed by lengthy rehabilitation and physical therapy. Last week, he caused a car accident and is back in the hospital, soon to go to another rehab facility. He is miserable, in pain, and non-communicative.

The kicker is that Sheila, rather than sinking deeper into the folds of the couch, has risen. She is becoming the competent one who deals with paperwork and arrangements and information. She has even started swimming three times a week.

In short, the worse he gets, the stronger she becomes. From my work, I know this is not an uncommon pattern - the under-functioning/ over-functioning couple.

Have you seen this pattern in your family? How about in your own relationship?

Grand Rounds at Health Business blog.

Grand Rounds is up at the Health Business Blog. Have a look. I'm pleased my post on doctor etiquette was included.

Etiquette-Based Medicine

This has nothing to do with couples and illness, but I was so surprised when I read this article, I had to blog about it.

One of the most prestigious medical journals in the world, the New England Journal of Medicine, just published an article on Etiquette-Based Medicine, by Michael W. Kahn.M.D.

Now you'd think this article would be about some cutting edge approach to medical care, along the lines of narrative medicine (a practice at the College of Physicians and Surgeons at Columbia University) or about some of the terrific scientific and social innovations that come from the The Cleveland Clinic, which is ranked among the four leading hospitals in America (US News & World Report, 2007).

But this NEJM article is really about etiquette. The article opens with the question:
"Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved?" The author goes on to say, "A doctor who has trouble feeling compassion for or even recognizing a patient's suffering can nevertheless behave in certain specified ways that will result in the patient's feeling well treated."

First of all, a doctor who is unable to feel compassion and can't see suffering when it's under his/her nose is, imho, not practicing excellent medicine and should probably be re-trained or re-positioned into a role that has less to do with direct patient care.

Second of all, do we really need to bring Miss Manners into the consulting room? Isn't that a bit insulting to doctors. Do they really need to be reminded to say hello and introduce themselves to the patient? Apparently so, according to the author. The basic manners include:

1. Ask permission to enter the room; wait for an answer.

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropriate.

5. Briefly explain your role on the team.

6. Ask the patient how he or she is feeling about being in the hospital.

"I may or may not be able to teach students or residents to be curious about the world, to see things through the patient's eyes, or to tolerate suffering. I think I can, however, train them to shake a patient's hand, sit down during a conversation, and pay attention. Such behavior provides the necessary — if not always sufficient — foundation for the patient to have a satisfying experience," writes the author.

I find this terribly sad. I am not my medical condition. And for my doctor to learn about my condition he/she has to go through me. If my doctor can't recognize suffering or have empathy (not sympathy), he/she is only getting a portion of the data, that which can be conveyed in simple answers to questions asked. The story I have to tell about my pain condition, for example, is bigger than answers to, "When did it start?" "How would you rate it on a 1-10 scale?"

I welcome doctors who are scientifically brilliant. I want to hear what they have to say about their area of expertise. And if they have good manners and can "smile if appropriate," I would even have a cup of tea with them. But I would never equate that with a "satisfying experience."

I don't need or want my doctor to weep with me. I don't want him/her to look deeply in my eyes, hold my hand and say, "I feel for your pain." But I do want my doctor to be able to make a genuine human connection with me - one that makes it possible for him/her to ask deeper questions and for me to give deeper answers. And who knows, that connection, that relationship may actually play a serious part in the healing process.

Saying Goodbye to a Good Dog

Ambrose Bierce in his Devil's Dictionary defines "DOG" this way:
"DOG, n. A kind of additional or subsidiary Deity designed to catch the overflow and surplus of the world's worship."


My sweet dog Mina died a year ago today, and I am ready to say goodbye. She came into my life when I was very sick with an uncontrollable pain condition. She was as important a part of my recovery as was my husband and my doctors. She gave me shelter in her heart -- that is what I felt every day of our time together. And, in the ways of a universe with a sense of irony, she died at age twelve from an enlarged heart. Her breeder had told us about her many gifts and promised that she would only disappoint us once. Mina kept that promise.

Here is the eulogy I shared with her many friends after she died:

As many of you know, Mina has been slowly declining over the past year. She has had a heart condition since she was young and has compensated masterfully for it over the years. Two days ago she went into serious respiratory distress, and last night we brought her into the emergency ward of Angell Memorial Animal Hospital. Despite their tireless efforts, she continued to deteriorate. She lay on her side, breathing rapidly, and was largely unresponsive. I called her name once, and she lifted her head. Our eyes met, and we said good-bye to each other. At 5:30 am on May 1st, just as the sun was rising, we brought her out of the hospital into the cool morning air and laid her down on her blanket under a tree. I held her as Richard knelt by her side. She was one month past her twelfth birthday when she died.

We have been blessed to have had her in our life for seven years. Every moment with her was an invitation to live with joy and equanimity. Her high-held, swishing tail was a signal to relish the day. Her determined sniffing as she hunted down the exact right spot to dig in to excavate some long buried chicken bone was a reminder to pay close attention to the concealed miracles that surround us. Her delight at reuniting with her beloved friends, all of you, called on us to deepen our own commitment to community. Her forbearance of our impatience when we needed to get going and she was still sniffing, was a gentle lesson in magnanimity. And her capacity for empathy while respecting boundaries is a power I will continue to strive to emulate.

One of her vets once said that some dogs are dogs; and others are people. Mina was people. I know that she left her paw mark on each of you. I also know that you share in our deep sadness in her passing. Mina always remembered her friends, no matter how much time passed since the last visit. Know that she loved you, and that your love made her life richer, as it does ours. May her imprint remain in all our hearts, and may all of us take what she gave us and express it in our lives.

Please join me in taking a moment to honor Mina and the animals in your life who give you love and shelter.