The Psychological Impact of Acute and Chronic Illness: A Practical Guide for Primary Care Physicians The Psychological Impact of Acute and Chronic Illness: A Practical Guide for Primary Care Physicians Tamara McClintock Greenberg,PsyD,MS San Francisco,CA Tamara McClintock Greenberg,Psy.D.,M.S. University ofCalifornia,San Francisco Langley Porter Psychiatric Institute San Francisco,CA 94143 Private Practice,San Francisco Library ofCongress Control Number:2006925258 ISBN-10:0-387-33682-6 ISBN-13:978-0387-336824 Printed on acid-free paper. © 2007 Springer Science+Business Media,LLC All rights reserved.This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media,LLC,233 Spring Street,New York, NY10013,USA),except for briefexcerpts in connection with reviews or scholarly analysis.Use in connection with any form of information storage and retrieval, electronic adaptation, computer software,or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication oftrade names,trademarks,service marks and similar terms,even ifthey are not identified as such,is not to be taken as an expression ofopinion as to whether or not they are subject to proprietary rights. 9 8 7 6 5 4 3 2 1 springer.com This book is dedicated to all ofthe patients who have taught me, through their courageous struggles with illness,about the impact and meaning ofthe diseases that plague us. T.M.G. FOREWORD I n the following pages, Dr. Greenberg delineates the complex forces at play within patients who are newly ill or disabled,within physicians who do their best to guide patients through those debilities,and in the interac- tion that patient–physician dyads perform thousands of times daily to try to make sense of the patient’s plight. As a physician and medical educator who thinks about how to enhance communication between patients and physicians,I often view communi- cation challenges as arising from divergent cultural experiences. Each patient has a unique method ofexperiencing,deriving meaning from,and coping with a new or chronic illness.This approach is necessarily filtered through the patient’s family and social contexts and the patient’s current living situation. Physicians,too,bring psychosocial upbringing and current social con- text into their clinical practice settings.We have also been inculcated into a medical culture that takes its bright,impressionable,idealistic young and shapes them, sometimes brutally, into diagnosticians and proceduralists. We are just now beginning to understand the many components of the “hidden curriculum”of many medical schools – unspoken but powerful influences in training that undercut the humanity of trainees and turn them into poorer communicators than when they first started. The challenge is to achieve and prioritize connection, both in medical education and in practice.Many ofmy procedure-based colleagues achieve vii viii ● FOREWORD this nonverbally,by fixing a problem,and many patients deeply appreciate their outcomes.An equally powerful connection forms through empathic witnessing of a patient’s situation,even if we cannot fully understand all that a patient might be undergoing.In addition,research suggests that the presence of an empathic statement in both medical and surgical settings can decrease the length of an outpatient encounter. Presumably, as clini- cians share that they understand what a patient might be undergoing,the patient leaves more satisfied.This outcome is clearly desirable for patients, physicians,and health care systems. The other day, I saw Mr.A, elderly in years but still sprightly.When I first met him, about four years ago, I found his communication style somewhat challenging. He would flit from subject to subject, most of which were nonmedical and which I deemed unimportant. He told me about classes he took at the local community college on spirituality and love.He told me ofhis son,his divorce,and continuing loving relationship with his ex-wife, his present friendships, and his continued sexual escapades, both consensual and individual. He showed me photos of his artwork and of himself when he was younger.Each time he left the office, I knew I was missing his point: somehow he was trying to tell me some- thing,but I was too dense,too distracted,and mostly too uninterested to figure it out.Anyway,it was onward immediately to the next patient,so I never stopped to think about it. Over time he had to have a total knee replacement, then a coronary bypass,and,most recently,urgent surgery for a humeral fracture suffered in a fall.Through these major procedures,Mr.A was sunny,upbeat,and completely (and a bit maddeningly) insistent on continuing to tell me tan- gential stories. So when I saw him on my schedule the other day,I was expecting more of the same. Instead, in walked a rather dour man dressed in gray and black,when I’d come to expect vibrant multiple colors.At once I knew that Mr.A had reached the limits of his substantial coping ability.Three suc- cessive surgical procedures and rehabilitation processes had finally taken their toll.He could neither walk nor lift his dominant arm without pain, and he began to despair that he would never regain full function. He’d stopped his numerous activities, was eating and sleeping poorly, clearly had low energy,and could not concentrate.Though he vehemently denied suicidal ideation.When I asked him,“Do you have any guilt?”,he instantly FOREWORD ● ix became tearful.He spoke ofhow he was re-evaluating his life and felt that he’d been terribly selfish with his ex-wife;maybe ifhe’d treated her better, they’d still be together.The loneliness was palpable.Now I understood the numerous activities and the flitting about better:they masked his pain. In diagnostician mode,I’d uncovered his obvious major depression (or was it a bit ofbipolarity? Maybe a bit ofhistrionic personality style mixed in?).But it finally became obvious why he’d told me so many stories that I’d previously discounted as irrelevant.He was telling me who he was.He’d given me an extraordinary gift ofletting me into his life,not just the com- partmentalized medical stuff,but how his illnesses related to him,Mr.A, the person,not the organism.In response,I’d left his gift unopened on my stoop,wondering if it would go away. Now that I could understand more about my own resistance to Mr.A’s stories,I found myselfmore fully appreciating him.As a doctor I often feel compelled,as Dr.Greenberg notes in Chapter 2,to action.Though Mr.A and I went through the obligatory discussion about antidepressants (see Chapter 5), I felt an important need just to be in the same space as he. Somewhere,deep inside,I was saying to myself,“Don’t just do something, be there.” By the end of the visit,Mr.A felt compelled to quote a poem of Edna St. Vincent Millay called ‘Love Is Not All.’ Though I’m generally not a “poetry person,”by his ability to reach through his depression into himself and share a piece of his passion with me,I knew that my low-tech inter- vention of empathic witnessing had succeeded. Calvin Chou,MD,PhD Associate Professor of Clinical Medicine University of California,San Francisco FOREWORD T his is a particularly challenging time in medicine.While our scientific knowledge is rapidly expanding, both patient and clinician satisfac- tion with our health care system is declining. Students enter medical school with strong humanistic and ethical ideals.Over the four years,they assimilate more knowledge than they knew possible.They are then faced with several years ofresidency when they must continue to acquire knowl- edge and skills while providing direct patient care.Given the enormity of this task,our education and health care systems encourage a primary focus on the traditional,evidence-based science ofmedicine.The psychology of illness is either assumed to be self-evident or is left to the purview ofmen- tal health professionals.This is not a realistic approach and not what most of us desire from our physicians. As individuals,nobody teaches us how to think about and respond to illness.Although virtually all medical schools now teach some form ofthe psychology of illness, most students attend first to the “hard” science courses, fitting in the “less scientific” courses as time permits. Residents quickly learn the frustration that comes from dealing only with the illness when they see Mrs.Smith back for her ninth admission in three months with the exact same symptoms.It’s as though they have the know-how to pull a car out of a skid,can tell people in detail how to respond,and then have to watch person after person go into a skid.Clearly,something more is needed. xi xii ● FOREWORD Dr.Greenberg examines the history ofillness and psychology,giving the reader a context for current beliefs and practices in Western medicine.It is generally acknowledged that certain illnesses,like asthma,have a psycho- somatic component.Unfortunately,many people think this means the ill- ness is in the sufferer’s head,that the symptoms are not real.Studies clearly show that mood state affects the outcome of a variety of illnesses, like coronary artery disease. Most physicians continue to focus on the hard facts: tests,treatments,etc.Most patients,however,care most about their ability to function and engage in their lives. Bringing her years of work as an astute and respected clinician,educa- tor, and colleague, Dr. Greenberg demystifies patients’ psychological needs,giving the reader an understanding ofand an approach to caring for the entire patient. We all have different coping strategies, roles, relation- ships,and predisposition to mental illness that are brought to bear in deal- ing with illness, which is among the most stressful tasks of living. As clinicians,we interact with the illness and the patient before us,as well as with their entire history,family,culture,and level of trust of the medical establishment. Although referral to a mental health practitioner in con- junction with ongoing primary care is sometimes the answer,it is neither possible nor desirable in all instances. Dr. Greenberg demonstrates the synthesis of medical and psychological approaches into a coherent treat- ment approach. This wonderful book is a must-read for all clinicians.Use it repeatedly as a reference;both you and your patients will benefit greatly. Lee Jones,MD Associate Dean for Student Affairs Professor,Department of Psychiatry UTHSC San Antonio