Call From ER

Sunday morning the call came from the service-the Emergency Room is looking for you. OK, so I was on my way out to walk the dogs along the Hudson River on a glorious late spring morning but...I was hoping it would be quick and painless.
"Emergency Room," she answered.
"Hi.  This is Dr. Benzil, I am returning the call to Dr. W."  I replied.
"Is HE available?" she volleyed back.
PAUSE-I wasn't sure what she meant so...
"This is Dr. Benzil, Is Dr. W. available?"  I tried a different tactic.
Still she seemed confused, "I will get her to the phone when HE picks up."
Finally I understood. "I am Dr. Benzil, a she not a he."
I imagined some light bulb turning on, "Oh, I will get Dr. W."

It is June 2011.  I have worked at this hospital and this ER for more than 7 years and do more cases there than any other neurosurgeon and yet, the deep seated notion of doctors (particularly neurosurgeons) as male clearly lives on.  Sigh, perhaps in the next decade...

The Social History

A  49 year old woman came to my office last week with 5 years of debilitating headaches.  Her neurological evaluation included an MRI which  revealed a pineal region cyst.  After several years getting interval MRIs focusing on this benign cyst until she took her care into her hands and sought the opinion of a neurosurgeon.  I looked through her extensive catalogue of MRIs and could confidently reassure her that this cyst was not a worry and not the source of her headaches.  She was relieved but asked the expected question, "Then what is causing my headaches?"  I think I know but before I answer let me divert for a moment...
Pain-in its many forms and expressions-is probably the greatest challenge for physicians.  You can't see it or touch it, there are no tests that reliably predict it or measure it (there are scales that are used but they remain completely subjective), and it is always a "symptom" rather than a diagnosis (think appendicitis as diagnosis/right lower abdominal pain as symptom OR brain tumor as diagnosis/headaches as symptom).  Despite all this, pain is always real-one might complain more than another or let it interfere with life more but anyone who comes to my office complaining of pain IS REALLY experiencing pain.  Because pain is the end product expression of many factors and modulations-both physical and psychological.  And to date, science has failed us miserably in understanding the real mechanics of pain.  Sure I could enumerate molecular knowledge about receptors, agonists, antagonists, signal transduction and the like but in the end, it wouldn't get any of us closer to understanding how and why patients suffer, how stress can bring on a headache or aggravate back pain, or how a wedding can temporarily halt longstanding cancer pain (as just a few examples of a myriad of pain enigmas).

Early in my career, I learned an invaluable lesson from an enormously gifted and talented plastic surgeon (who I count as both friend and mentor), Dr. Jane Petro.  We were jointly running a peripheral nerve clinic and had to evaluate a patient with RSD (Reflex Sympathetic Dystrophy as it was known then, now referred to as Complex Regional Pain Syndrone-CRPS).  After the patient left, she engaged the team in a discussion of a striking paper that demonstrated the very high correlation of RSD with abuse (both child and spousal abuse) (References below).  The clear implication was that our life events clearly impact our response to injury and disease in ways that remain unknown to us.  But while we may not understand the mechanism, it is evident that all health care providers have to more closely attend to understanding the lives of our patients in order to administer to their medical needs.
Which brings me to the Social History-probably the most under-rated component of a patient's history (beyond the perfunctory smoking, alcohol, and drug history).  Despite the pressures and my role as a sub-specialist, I always ask a few questions about home, employment and background.  At the least, I know a few things about my patient and it helps me view them as people (fathers, sisters, colleagues, etc.).  And sometimes the information turns out to be critical for successful outcomes or interventions.  For example, I recently performed a spinal fusion on a woman who was clearly in a threatening marriage and based on that information, I made sure she went to rehab post-op, even though she was likely medically well enough to go directly home.
So how does this all relate to my headache patient? Well, by just asking one simple question, she revealed a recent divorce after several years of a nasty separation.  Clearly, her headaches were temporally related to the onset of marital strife.   Trust me, this woman truly suffers from terrible headaches-they are real and life-altering, neither imagined nor exaggerated.  How? I don't know. Why headaches and not some other complaint? I don't know.  What is the best intervention now for this woman? I don't know.
But I do know, taking the Social History remains a critical component of understanding and providing the best care to our patients.

References:
Abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence. - Wuest J - Pain Med - 01-MAY-2009; 10(4): 739-47

Prevalence of interpersonal abuse in primary care patients prescribed opioids for chronic pain. - Balousek S - J Gen Intern Med - 01-SEP-2007; 22(9): 1268-73

Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis. - Ciccone DS - Clin J Pain - 01-SEP-2005; 21(5): 378-86

Psychologic factors in the development of complex regional pain syndrome: history, myth, and evidence. - Feliu MH -Clin J Pain - 01-MAR-2010; 26(3): 258-63

Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed.; CHAPTER 82 - Domestic Violence

Katz: Comprehensive Gynecology, 5th ed.; Chapter 10 - Rape, Incest, and Domestic Violence

Relief

He took himself to Ghana
To search his inner soul
Or so he told us,
When he clearly failed all else.

At first the stories flowed
Through Internet Cafes
New friends, new loves, new life
The experience of a life!

But then the current stopped
No calls or otherwise
A few days then weeks flew by
I imagined so very much

And just like that it came
A call from another shore
All fine, not even aware
Of a mother's eternal woe


Note:  Thanksgiving may be past but today I am thankful all over that all is well.

My Nudge Contest

nudge 
tr.v. nudged, nudg·ing, nudg·esTo push against gently, especially in order to gain attention or give a signal.
nudge or nudzh or noodge Slang (Yiddish)
n.  One who persistently pesters, annoys, or complains.

Of these definitions, my Yiddish-flecked childhood reflected primarily the latter. So, thanks to Howard Luks for first bringing the notion of using the nudge (ie first definition) to medical use and studies that have shown the clear effectiveness in areas such as diet and exercise.  For those who haven't had the time to absorb the ever-expanding global world of nudges, I can recommend the nudge blog by Thaler and Sunstein devolved from their book of the same title.  The concept has acquired so much traction there has been a serious call for research into the effective use of the nudge in medicine.  Already in Australia, when filling a prescription, an Aussie can enroll in a nudge club that will prompt proper use of the medication.  The daily nudge is a service you can use to create your own health inducing nudges.

So here is my challenge: Submit you best idea on how to use THE NUDGE  to promote health!  Think big or small, technical or spiritual, systems or individual.  Humor welcome.  Please submit to: womenneurosurgeo@aol.com

Fool me Once

Fooled me
Last summer, all summer
Out late
Many lies
Wasted work
The graduate! Ha!

Fooled me
Freshman blues
More lies
Wasted time
Opportunity lost

Fooled me
Said you blundered
Wanted help
Change would come
Had ideas

Fooled me
Summer home
Big plans
Getting it right
Taking control

Fooled me
Deceit everywhere
Where to turn?
What to do?
Is it too late?

Fooled me
Once, twice
Again, again
Fooled me
Me Fool


George Bush: Fool Me Gaff (must watch!)

A Story I Have to Tell

Fernando Botero's: After Velazquez

On the intake sheet it only said "second opinion" so I had no idea when i walked into the examination room and was greeted by my patient and her mother.  She was a lovely young woman complaining of more than 10 years of back pain with debilitating progression.  This woman was also coping with psychotic schizophrenia (on three controlling medications) and suffering from morbid obesity (5'4" an 310 lbs).  Her exam showed no significant neurological impairment.  However, her MRI revealed a large ruptured disc and also the ravages of degeneration from the extra stress of her body habitus.
I began my usual explanation about ruptured discs and treatment options but had to conclude by informing her I would not consider surgery for a number of reasons all related to her obesity (the high rate of surgical complications, the likelihood of significant residual pain related to the widespread deterioration of her spine, her inability to exercise and adequately mobilize after surgery just a few of many).  I went on guardedly to make sure she understood that it wasn't that I didn't want to help her or that I was prejudiced about her weight and then moved on to my recommendation that she strongly consider surgical treatment for her obesity. I finished, so I thought, on a positive note saying that with the rapid weight loss one could expect, we might be able to consider surgical treatment for her back in less than a year.
I stopped talking after inviting any questions and there was absolute silence.  It took great restraint to let her speak next-the pause was so prolonged.  Her mother took my cue and also waited.
"It won't work," she finally blurted out,"I am a compulsive eater and so I know I will fail any surgical intervention because I don't have any control." Gratefully, her mother took up the conversation with her own story of surgical weight loss and subsequent reversal of the ravages of uncontrolled diabetes.  My patient responded again with a plaintive, "Won't work, I am psychologically impaired and I like to eat too much."
I smiled, it was time for me to end my silence. Gently I offered that many of US were compulsive eaters who loved to eat and that her weight issues were separate fro her other problems.  I realized that she had always linked the two and knew (rightly) that she would never conquer her mental illness, only keep it controlled (mostly with strong medications) for periods of time.  Thus she had come to think of her eating has a fait accompli, too.
I doubt I will see her in my operating room any time soon but I knew by her and her mother's beaming smiles that I had offered them something even better-perhaps a fresh start.  And they had given me something-the intangible gift of a patient helping you to understand something about the world and yourself that otherwise would have remained elusive.