Technicians or Physicians

OtolaryngologyHead and Neck Surgery Volume 119 Number 1

LETIERS TO THE EDITOR

Allergic Fungal Sinusitis: Immunotherapy as Part of the Treatment Plan To the Editor: I am writing in response to the two recent articles about allergic fungal sinusitis (AFS), which appeared in the July 1997 issue of the Journal. I have treated several patients with AFS and would like to comment on the approach that I have used. During the preoperative visits I perform a mRAST test with special attention for hypersensitivity to fungus/molds, total IgE, and fungal-specific IgE. From this, I determine the specific allergens, especially fungus, to which the patient is sensitive. The patient is then given an oral antihistamine and steroid nasal spray; oral steroids are give before surgery. In the postoperative period, the patient continues to use the nasal steroid spray (usually budesonide), the oral antihistamine (loratadine or cetirizine), and saline irrigations, and immunotherapy is initiated. The patient is seen frequently, and at the first endoscopic evidence of recurrence, the patient begins receiving oral steroids, and the nasal steroid inhaler is switched to dexamethasone (course of 4 to 6 weeks); immunotherapy is continued. The above regimen has helped control this disease and reduce the number of revision surgeries. I believe that the initiation of immunotherapy is beneficial because it desensitizes patients to the very allergens that are the cause of their disease. It is the patients' sensitivity to the fungal allergens that initiates the process of AFS. Of course, further research is needed in the arena of immunotherapy, but I forsee immunotherapy as a mainstay in the treatment regimen of AFS. Myron W Yencha, MD U.S. Naval Hospital PSC 475 Box 1604 FPO AP 96350-1604

Yokosuka. Japan

23/8/88806

Technicians or Physicians To the Editor: On a Monday in September, I felt the earth shudder. Although I was in San Francisco at the Academy meeting, this was not a geological event. I was sitting in the Scientific Session on Pediatric Otolaryngology and listening to a presentation on a clinical practice guideline (CPG). In brief, the paper indicated that if a nurse calls the family for follow-up after a tonsillectomy, there is no need for the surgeon to see the patient in 80% of cases. This was a paper designed to produce a CPG that will be used by the ever present, highly paid, managed care executives. As I listened to this brief presentation, I became angry. Does this mean that my job is done when I remove the mouth

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gag? Does this mean that my relationship with the patient and the family has no role in healing? That is simply wrong. At the meeting I also attended a talk by Rachel Naomi Remen (not nearly as well attended as the Scientific Session), which reinforced my own reaction. She helped me synthesize my feelings, and reading her book, Kitchen Table Wisdom, has continued the process. Healing is different from fixing. I can fix the tonsils, but healing is a complex process that has many components. As surgeons, we are also in need of healing. Through the relationship that we form with our patients, we can create a healing environment in which healing takes place for patient, family, and physician. Let's start with the patient. There is an abundance of evidence that attitude affects healing. Anxiety and depression have a negative effect on healing. In primitive societies, belief systems can lead to illness and even death without apparent medical cause. 1,2 A patient who feels supported and cared for is in the best possible condition for healing. Before all of our technology, the laying on of hands was accepted as an important part of healing. Although often unacknowledged, it is still important. The physician who is able to hold a patient's hands, to touch a shoulder, to hug a grateful patient or a sad one creates a healing environment. The family is an essential part of the healing process, Few of us live in a vacuum, and most patients will have some family who are concerned and whose state of mind will have an impact on the patient's healing. This is more noticeable with children and elderly patients. Anyone who is immediately postoperative may have difficulty remembering anything in detail. A physician who communicates well with the family has an advocate and assistant in the patient's recovery. A concerned family member who understands the medical issues can keep a disoriented patient from climbing out of bed and an NPO patient from eating, and can ensure that postoperative medications are taken correctly. A family member who is considered an irritant and a waste of the surgeon's time is less likely to be an adjuvant to healing. When the patient has surgery, the family is wounded. Even in the simplest, shortest operation, the family is hurting. Their worry about their child, parent, spouse, or friend is a drain on them. A caring, concerned physician who is able to listen and hear their concerns will help the family to heal, and they can then help the patient to heal. An anxious family dealing with an impatient surgeon remains anxious. Their anxiety is transmitted to the patient, and healing is impaired. What about us? Although we rarely acknowledge it, we are also wounded. We work in a high-stress profession. Measurements of surgeons' vital signs during surgery show that even during the most routine procedures we undergo substantial stress, and that's when things are going well,3 Who among us would deny the stress of a bad result, a rocky recovery, or an intraoperative disaster? How do we heal?

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OtolaryngologyHead and Neck Surgery July 1998

LETTERS TO THE EDITOR

When we create a healing environment with the patient and the family, we allow ourselves to heal also. When we let them know that we are hurt by a bad result and that we find joy in a good one; they can help to heal us. When we give them the opportunity to give back to us by telling us how much our concern means to them, when we accept the hugs they offer, when we indicate by not distancing ourselves that we are open to hear from them, we allow them to help heal us. The healing environment makes a space for everyone, patient, family, physician. Everyone gains, regardless of the surgical result. It is possible that the most gain occurs when the surgical results are worst. That is when everyone is most in need of healing. Which brings me back to my original concern. How much help are we going to give managed care in making us superfluous? Are we going to produce studies that will make us mere technicians? Should we not be doing studies that show the importance of the healing relationship? Is a postoperative visit a waste of time? It is an opportunity for the family to tell me how their child is doing, to express their joy that things are better. It is an opportunity for them to give to me the joy that I have done something for them and for their child. One of my colleagues suggested that since the parents are missing work, the visit is a waste of time for them. I do not believe that. I believe that if we ask, they will tell us that the visit created a healing opportunity and a chance for them to return something to us. They may not realize that they are healing us, but I think they sense that something important is happening. All of this assumes that we are not talking about a 20-second postoperative visit. It assumes that there are a few minutes in which an exchange can take place. I believe that giving the patient and the family a space in which to express their concerns and their gratitude is an essential part of healing, even when the mucosa is intact. I believe that we as a community, physicians and patients and families, should fight for that right. I am in private practice and can see my postoperative patients if I so choose. However, if this CPG becomes a standard of care, and if I am salaried by a multispecialty group, they could say to me, "This is a waste of your time, and since we pay for your time, you cannot see your postoperative patients." We cannot let that happen. We cannot let that become our standard of care, for we are not technicians, we are physicians. Our healing role does not begin and end in the operating room. Our healing touch, our care and concern, our own need for healing is too essential to give up.

This is a call for us to produce studies showing that care is what patients want. Can we show that a healing environment saves dollars? I don't know, but I believe that we can encourage our patients to advocate for themselves and for us. I believe we can survey our patients and present their concerns to the managed care companies. I believe that we can and should keep a constant pressure through the media and through our relationship with our patients so that we are not forced into a corner before we realize that we are there. I believe that we can influence this process if we persist in protecting our role as healers. If we can enlist our patients, their families, and our colleagues in doing this, we will be formidable opponents to those who would become billionaires at the expense of healing. Carol Roberts Gerson, MD, FACS, FMP Children's Memorial Medical Center Pediatric ENT, Ltd. 2308 Lincoln Ave. Chicago, IL 60614 23/8/89068 REFERENCES 1 Meador CK. Hex death. voodoo magic or persuasion? South Med J 1992;85:244-7. 2. Eastwell HD. Voodoo death m Australian aborigmes. Psychiatric Medicme 1987;5:71-3. 3. Cyzewska E. Kiczka K. Czarnecki A et al. The surgeon's mental load during deCision making at varIOus stages of operations. Eur J Appl Physio11983;5J :441-6.

Cervical Sympathetic Schwannoma To the Editor: In the December issue of the Journal, Drs. Sheridan and Yim (1997;1l7:S206-IO) assert that they have tabulated all of the cervical sympathetic schwannomas cited in the English literature. They may have overlooked the following: Myssiorek D, Silver CE, Valdes ME. Schwannoma of the cervical sympathetic chain. J Laryngol Otol 1988;102:962-5. David Myssiorek, MD, FACS Department of Otolaryngology and Communicative Disorders Albert Einstein College of Medicine Long Island Jewish Medical Center New Hyde Park, NY 11040 23/8/89435