Case Studies in Self-Care

One of the keystones of medical education is the Clinical Pathological Conference (CPC), a teaching session where medical students and physicians meet to discuss one person’s medical problem—complete with lab tests, x-rays, and a day-by-day description of what happened.

A layperson walking into a CPC would have very little idea of what was going on. In one recent CPC, reprinted in the New England Journal of Medicine, the presenting resident required 273 closely packed lines of dense type to tell a story that began, “A 56 year-old man was admitted to the hospital because of hypoglycemia,” and ended, “The patient died on the 24th hospital day.” The story that came between included 180 lab test results, x-ray findings, and data from other diagnostic procedures.
While attending a recent CPC, I found myself thinking of a discussion I’d had with a physician who had expressed doubts about self-care. “It’s taken me seven years of training and 20 years of practice to learn what I know,” he said. “Are you telling me some housewife from Dubuque is going to be able to learn all that? No way.”

I sat in the darkened amphitheatre listening to the resident rattling off lab values and pictured Joan Q. Public, the housewife from Dubuque, sitting there beside me, peering down at a difficult kidney x-ray. If this was the kind of medical knowledge we were talking about, my doctor friend would be right. But it’s not. Joan Q. would probably feel just as baffled if she walked into a graduate seminar on number theory or linguistics but that doesn’t keep her from knowing how to count and read and write.

The problem is that we have defined “medicine” in such professionalized terms that it is hard for us to picture ways that laypeople can be knowledgeable about and responsible for health.

The health skills Joan Q. needs are not found among the dozens of lab values, x-rays, and microscope slides. They are of a different order. She needs to be able to:

• Examine her daughter’s throat and lymph nodes and take a throat culture when she has a sore throat,
• Develop a personal support network of family and close friends,
• Understand how her present habits and behaviors affect her chances of future disease,
• Insist that her doctor talk with her, negotiate with her, and treat her as an equal, and
• Find good information on any medical condition or wellness practice of concern to her or her family.
  Attending a CPC would not help Joan develop these skills. What would help her is to be exposed to such models of self responsibility in health as:

• Adam Z., who was convinced that his condition had been incorrectly diagnosed, tracked down some new studies his doctor didn’t know about, got a second opinion, and found out that he was right.
• Edith R. who has been taking her children’s throat cultures for five years.
• Norman Cousins, who, told by his doctor that he had one chance in 500 of surviving his disease, devised his own treatment (high doses of vitamin C, stress reduction, and laughter therapy) which did the trick.
• Glenn Nugent, who, told he would die of heart disease unless he had bypass surgery, brought himself back to vigorous health by a strict diet, an exercise program, and membership in a support group for people with atherosclerotic disease.

Both children and adults should be exposed to such examples just as systematically as our physicians are subjected to the kinds of stories one finds in a CPC. We’re planning to run more of these case studies in self-care future issues, and would welcome your suggestions of further examples and other ways to use them.