Month: February 2011

Keith Johnstone wrote an excellent book called Impro:

---

I’m remembering [the psychotic teenaged girl] now because of an interaction she had with a very gentle, motherly schoolteacher…. We were in a beautiful garden (where the teenager had just seen God) and the teacher picked up a flower and said: “Look at the pretty flower, Betty.”

Betty, filled with spiritual radiance, said, “All the flowers are beautiful.”

“Ah,” said the teacher, blocking her, “but this flower is especially beautiful.”

Betty rolled on the ground screaming, and it took a while to calm her. Nobody seemed to notice that she was screaming “Can’t you see? Can’t you see!”

In the gentlest possible way, this teacher had been very violent. She was insisting on categorising, and on selecting. Actually it is crazy to insist that one flower is especially beautiful in a whole garden of flowers, but the teacher is allowed to do this, and is not perceived by sane people as violent. (p. 15-16)

Though Johnstone’s book is ostensibly for students of theatre, his text is immensely useful for teachers of all types. Furthermore, the chapter “Status” might teach more concrete information about human behavior and dynamics than psychology and psychiatry textbooks.

I still firmly believe that improv classes (and partner dance classes—really) help train people to become better doctors. Both employ the “Yes, and…” strategy, which encourages engagement, rapport, and collaboration. Doctors must cultivate those three skills to make health care work well. Otherwise, we, too, might engage in gentle violence.

During the third year of medical school, students are released into hospitals and clinics to interact with actual patients, doctors, and medical systems. On our first day as third-year medical students, my classmates and I each received a key card. It was a light shade of grey, had an uneven surface on one side, and easily slid into the sleeve that held our identification.

The hospital administration admonished: “Keep your key card in a safe place. Do not lose it.”

The key card unlocked all of the doors in the hospital. Just 24 hours prior—when I was a second-year medical student—I had to register as a hospital visitor and wait for people to guide me through the building. Now, things had completely changed.

After tapping the key card against the electronic panel outside of the trauma surgery ward, the lock on the door disengaged. I pulled the door open and inside were patients with various limbs elevated, wrapped in gauze, with metal rods and screws sticking straight out of their flesh.

The heavy doors of the intensive care units automatically swung open with the tap of my key card. The sighs of mechanical ventilators and various beeps from heart monitors greeted me. I spied silent, yawning people sitting by unconscious patients. Tubes jutted out from their slack-jawed mouths and numerous clear tubes trailed from their bodies to the IV poles towering over them.

The key card allowed me to step into the maternity ward. No one cast a wary glance at me when I peered at the rows of newborn babies in the nursery.

With that key card I learned that the entire hospital, with all of its sacred spaces, was open to me. I felt both terror and delight. Did they not know that I had no idea what to do? Couldn’t everyone sense that I did not belong there? I avoided eye contact with all other human beings and hastened my gait to assure everyone I was not loitering. I didn’t want to give anyone the impression that I was trying to take care of patients.

No one noticed. In some instances, I used my key card to open a door, took literally two steps into the area, then walked right back out again. Doctors and nurses seemed to look straight through me.

At the end of the day, I used my key card to leave the hospital through an unofficial exit. The heavy heat of the July evening immediately walloped me, along with a humbling realization: Now that my classmates and I were allowed into these sacred spaces, we had power and privilege.

Doctors often forget that patients can invite us into the sacred spaces of their lives. They share their physical and emotional vulnerabilities with us. We learn about their health, illnesses, fears, and hopes.

We, however, do not automatically receive key cards to patients’ lives when we first meet them. We can only earn these invitations through respect, professionalism, and competency. We must remember that, as with hospital key cards, we should do our best never to lose those skills.

Mr. Smith tolerated the surgery well. The anesthesia wore off quickly. One of the wheels of his gurney clattered as the orderly pushed him down the hallway towards his room. His mother, wringing her hands, wordlessly rushed towards him when he entered. She cried.

That night, his mother slept on two chairs next to his bed, as if she was guarding the wound.

Mr. Smith said little about the amputation of his left leg. He commented that the car accident was just that—an accident—and, now, he wanted to look forward, not back. The doctors and nurses marveled at his serenity. They wished all of their patients were calm like him.

The next morning, his sister came by. She brought a box full of family photographs with her. While Mr. Smith watched, his sister and mother taped them to the window. The photos formed a large “S” that occupied the entire pane. He was pleased with their handiwork.

The visitors began to trickle in that afternoon. Some were teenagers; others were about to retire. A few came in wearing tailored suits, but most were in jeans and tee shirts. Nearly all of them came alone. They told the clerk that they were Mr. Smith’s friends. The clerk often had to ask them to wait because there were already too many people in his room. Most spent less than 15 minutes with him.

A nurse turned off the lights in his room that night. Mr. Smith objected. He said he could sleep in a lit room. If he woke up, he wanted to see who was coming in. The nurse turned the light back on.

A few visitors came later. When the nurses told them that they could not see Mr. Smith, some of them became angry. They had travelled far to see him. Couldn’t the nurses make exceptions? When the nurses instructed them to come back during visiting hours, they muttered obscenities.

This went on for two days.

Meanwhile, some of the nurses noticed that the dressing around the stump of Mr. Smith’s left leg was often loose. While rewrapping the gauze, they told him to let them know if he noticed the dressing was falling off. To help the wound heal, it should be snugly wrapped at all times. Wincing, Mr. Smith agreed.

On the afternoon of the third day, screams and shouts came from Mr. Smith’s room. Nurses ran in and saw a male visitor leaning over the bed. His fist was over Mr. Smith’s head.

The nurses demanded to know what was happening. Mr. Smith said nothing. The angry man said nothing. The two other visitors in the room stared at the floor. The angry man abruptly left.

Twenty minutes later, four police officers burst onto Mr. Smith’s floor. The nurses chased after them, loudly asking for the reason for their visit. The police said that they wanted to arrest the man in the room with the S on his window. The nurses protested.

Mr. Smith was sleeping when the police surrounded his bed. Doctors arrived. His mother fled. The police asked the doctors to remove the dressing from his wound. Mr. Smith, calmly looking around, asked if it could be done later. The police insisted.

And this is how everyone learned that in the wound of his amputated leg was a stash of cocaine that he was selling to his visitors.

Antidepressants, like other medications, cereals, tee-shirts, and frozen vegetables, come in trademark and generic varieties. What is the cost of one month’s worth of generic medication? How about one month’s worth of trademark medication?

The generic name for Prozac is fluoxetine:

According to drugstore.com, 40mg of fluoxetine costs $40.99 per month. 40mg of Prozac costs $398.49 per month. Prozac went off patent in August 2001.

The generic name for Paxil is paroxetine:

Paxil went off patent in 2003.

The generic name for Zoloft is sertraline:

Zoloft went off patent in 2005.

The generic name for Celexa is citalopram:

Celexa went off patent in 2003.

Here is a comparison of the costs of trademarked antidepressants:

Lexapro (a cousin of Celexa) and Cymbalta are currently under patent. No generic forms are available at this time.

Why does Prozac remain expensive? Why is Lexapro relatively inexpensive?

If doctors knew the costs of these medications, would they change their prescribing preferences?

If patients knew the costs of these medications, would they ask their doctors more questions?

(All price data above are from drugstore.com. Patent expiration dates come from a variety of business magazines. I created the graphs using Google Docs.)

How did you first notice the lump in your breast?”

The sadness in her face momentarily disappeared. She laughed.

“My husband found it.”