Diagnosis: Data

When your symptoms don’t tell the whole story

Dan Gorenstein Sep 24, 2013
Diagnosis: Data

When your symptoms don’t tell the whole story

Dan Gorenstein Sep 24, 2013

Instead of asking you to talk about the pain in your foot, or the ache in your chest, health care workers are starting to ask you about…your story.

There’s an emerging idea in health care that social and psychological conditions — like poverty and chronic stress — change how your body and brain work, and that can have damaging long-term effects on your health.

Doctors and nurses from northern California to Camden, N.J., are beginning to see that the first step in treating these patients is often treating the part of the illness that’s not on the surface. Patients like 30-year-old Elizabeth Philkill.

For years, she’d kept her past buried inside. “Some things you do not expose. It’s a judgmental world,” she said.

But in a quiet room with Renee Murray — a nurse and a virtual stranger — Philkill finally told the story that she’d shared with only two people in her life.

She told Murray, she’d been sexually abused for years as a child. And that one night a few months ago, she’d had a terrible dream that forced her back to those days. And that she wanted to forget. Fast.

So she made the call. “I called to get me some wet. I made it through it, bam,” she said.

Nurse Murray, who runs a program for underserved pregnant women in a Camden, knew what the drug could do.

“’Wet’ is marijuana with PCP dipped in formaldehyde and you smoke it. You are not on our earth anymore when you are high on wet.”

Philkill was three months pregnant at the time.

Outwardly, Murray didn’t react to the fact that Philkill had endangered her baby, and herself. She wanted Philkill to feel safe, to keep talking.

Murray had recently been trained  in what’s known as ‘motivational interviewing,’ a way of getting patients to open up.

“I was thinking like, ‘yeah, this is crazy,'” she said. “Someone who is pregnant doing this drug that you hear all these horror stories about. But, as a nurse, that’s my job. My job is to sit here and to learn Elizabeth’s story. Because if I don’t learn her story, I can’t do my job.”

The approach worked. “She don’t know me from a can of paint, and she care about me then people that should care cares,” said Philkill. “So it made me get out what I didn’t want to expose. You know what I am saying, it made me go deeper as to why did you smoke wet.”

In Camden and around the country, this listening technique — a first step in changing behavior — is catching on because it’s seen as a way to help treat patients who, like Philkill,  are tough to reach.

But here’s the big idea; researchers are learning that the prolonged chronic stress that comes with worrying about food, safety and money can make people sick.

British epidemiologist Michael Marmot says people who suffer from chronic or “toxic” stress, are more susceptible to chronic disease like and early death.

“What’s only come to light over the last decade or so.” Marmot said, “is if a child is exposed to a stressful environment, an abusive environment that affects brain structures, that can actually change the architecture of the central nervous system.”

And, Marmot says, this can happen to anyone — young or old, poor or rich — if they feel a sense of helplessness, or constant danger. “Where the threat is uncontrollable. You are threatened by a wild animal, you run away from the wild animal. You escape, then you recover. That’s what’s supposed to happen. But imagine you can’t get away from this wild animal, it never actually tears you apart, it’s just threatening you all the time,” he says.

Marmot is primarily concerned with the physiological effects from long-term threats.

Princeton psychologist Eldar Shafir, who co-wrote the book “Scarcity,” is focused on more immediate stresses, particularly economic ones. He says money, trouble, and especially poverty, takes away your ability to think about anything other than what’s right in front of you.

“The rent this month is questionable, that dinner is not yet taken care of, those financial impositions take a load on your mind and leave less mind for other things to handle,” he says. Things like going to the doctor and taking your medicine.

This lack of bandwidth is particularly damaging to people with chronic conditions, like diabetes and heart disease, that demand constant attention.

That patients make up a small fraction of the sick, but they are responsible for the majority of health care spending.

Medicare thinks the connection between trauma and chronic illness is important enough that it has invested nearly $20 million, in a multi-state project. It’s based on a model designed by Dr. Alan Glaseroff from Stanford.

“This work begins by asking the question, ‘Why wouldn’t a person with a chronic condition do everything in their power to live long and feel well?'” he says. “And generally there is sort of a subtext, ‘What is wrong with this person, they are not listening to me.'”

At his clinic, Glaseroff sees 160 privately insured patients, who racked up $58,000 a year, on average, in medical bills before he began treating them.

Glaseroff directs his team to focus first on what matters to a patient like dancing at his daughter’s wedding, for instance. Then they deal with the fact that the patient is diabetic and smokes three packs a day.

Glaseroff says his approach has helped shave 20 percent off his patient’s medical costs. He says if the model succeeds in other states, “It will be a huge step forward.”

It’s the kind of step nurse Renee Murray is trying to take with Elizabeth Philkill back in Camden.

“When you are dealing with people that have complex issues, if they are not ready to get the care they need or make a behavior change, it’s not going to happen. This approach gets them a little bit closer because now there is a healthcare provider who is showing a genuine interest in their life,” she says.

But Murray is a realist. She knows Philkill’s life is rocky — she has no job and no permanent place to live.

Since her talk with Murray, Philkill has  disappeared from her pre-natal class for weeks at a time. She has also had her phone turned off, and she continues to smoke cigarettes.

Even with all that, she did show up for class this week.

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