TUESDAY, AUGUST 3, 2010


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‘Camping’ employs tenets of cognitive behavior therapy


“Virtual Camping” is purely a demonstration, according to its founder, psychologist Jonathan Grayson. The exercise is designed to spur participants into therapy or to reinforce goals of their cur- rent treatment modality; it is not intended as a treatment in and of itself. The two main treatment av- enues for obsessive-compulsive disorder are psychotherapy and medication. Often, a combination of the two works best.


Antidepressants are popular


medications for OCD, according to the Web site of the Mayo Clinic in Rochester, Minn.; that’s be- cause many antidepressants in- crease levels of serotonin, which may be low in individuals with OCD. The therapy recommended most often is cognitive behavior therapy, which involves retraining a patient’s thought patterns and behaviors in the hope of eliminat- ing compulsive routines and ritu- als.


A type of cognitive behavior


therapy called exposure and re- sponse prevention, or ERP, is con- sidered the most effective therapy for OCD, said Stephen Whiteside, a psychologist and director of the Child and Adolescent Anxiety Dis- orders Program at the Mayo Clin- ic. Grayson’s “Virtual Camping” events employ principles of ERP. The technique involves expos- ing a person to the object or situa- tion he obsesses over, such as dirt or germs, and allowing anxiety to build. (That’s the exposure.) The person then commits to not en- gaging in his usual compulsive be- havior or rituals, such as excessive hand washing, and instead sits with the anxiety until it begins to dissipate. (That’s the response prevention.) The cycle of exposure and response prevention is con- tinued for weeks or months, until the patient is no longer troubled by obsessions or compulsions. “It’s a way of learning from your


own experience that OCD fears that you have don’t come true and that anything that does happen is usually something you can han- dle,” Whiteside said. Some therapists begin exposure


therapy by having the patient con- front his most-feared stimuli; oth- ers take a gradual approach, such as asking the patient to think about the situation that he most fears. In rare cases, when medication and therapy aren’t helpful, hospi- talization, electroconvulsive therapy, transcranial magnetic stimulation and deep-brain stimulation may be considered. —Dana Scarton


K


E5 Volunteers bring dental care outdoors clinic continued from E1


ties descends upon Wise, set- ting up exam rooms and surger- ies, a laboratory and a pharma- cy. Then they go to work, offering gynecological exams, vision and hearing tests, dia- betes and cardiology care, chest X-rays and cancer screenings. They stitch up wounds and re- move cysts.


But this year as usual, the ma-


jority of the 2,347 patients who came to the clinic in Wise, who slept in tents and in trucks and who lined up at dawn each morning, wanted to see a den- tist.


An imperfect solution


Dentists, especially those who serve the poor, can be scarce in these rural places. And even after the health-care over- haul, public and private insur- ance coverage to help pay for the dental care can be hard to find. Medicaid, the government health plan for the poor, entitles children to routine dental ser- vices, but not adults. Mean- while, private dental benefits are also often out of reach. More than 100 million Americans lacked dental coverage even be- fore the recession and its atten- dant job losses. Paying for care out-of-pocket is an option for some people, but for the financially stretched, dental work can take a back seat to other needs, such as food, fuel and housing. “I just can’t afford it,” said Lu- cinda Honaker from the town of Honaker, Va., named for the forebears of her husband, Charles, a miner disabled 10 years ago by diabetes. Their children have a dentist, but she and her husband do not. “The kids have got Medicaid, but no one will see us,” Lucinda Honaker said. The family lives on about $800 a month. So den- tal problems steadily progress, causing infection, pain and dif- ficulties with speaking and eat- ing. Ultimately the only answer is extraction, but it can be an imperfect solution. Charles Honaker had his in-


fected teeth pulled two years ago at a RAM event, but he is still on a long waiting list for free dentures. With the help of the family vegetable garden, he is trying to eat right to keep his diabetes under control. But without teeth he finds it


Brooke Hahne breaks into tears after touching some chewed gum.


hard. “For the stuff I’ve got to eat, I need teeth,” he said. In the meantime, he just cuts his food into tiny bits and swallows the small pieces whole. For many other poor people, cheap, sugar-laden foods and sodas have become dietary sta- ples that play havoc with the teeth. And tragically, the bacter- ia that feed on the sugar and ac- tually cause the decay are trans- missible, so parents, by sharing a spoon or testing the baby’s milk, can pass their legacy of dental disease on to their chil- dren. In places lacking preven- tive care and oral health educa- tion, decay easily runs rampant.


PHOTOS BY MICHAEL S. WILLIAMSON/THE WASHINGTON POST Temporary dentures are crafted overnight for patients who will later receive permanent fittings to replace their damaged teeth.


Kevin King shows the tickets he received for himself and his uncle as he entered the fairgrounds. Patients slept in tents and in trucks and lined up at dawn each morning.


on washingtonpost.com


Teresa Casey looks at her new dentures in a mirror. She had 23 teeth pulled a year ago after a bout with cancer and bone disease.


‘Rugged dentistry’ Growing up as the children of union miners, the Honakers, like many of their neighbors, re- ceived good dental care. But many of the mines have closed, and the jobs and benefits have disappeared. The economic downturn has made life even harder in the past two years. In fact, this annual clinic has be- come the only source of dental care for many local people. “It’s rugged dentistry,” said


North Carolina dentist Brittany Semones, pausing amid the mountains of stainless-steel in- struments sterilized and set out for the volunteer dentists on long folding tables.


Semones said she misses the


comforts of her own instru- ments, but this clinic is impor- tant to her. “It’s rewarding,” she said. “We get a lot of hugs.” As if


on cue, Semones finished with a difficult extraction and her pa- tient, Dianne Stiltner, a 54-year- old woman from Prader, Va., rose from the chair and em- braced Semones. Likewise, Charles Fogarty, 42,


a disabled forestry worker from Big Stone Gap, Va., said he was deeply grateful for the expert care he found at Wise. He said he once pulled out one of his own aching teeth with a pair of pliers. “I’ve had a pretty rough life,”


he said. A handful of volunteer dental technicians, who converted the fairgrounds’ wood-and-cinder- block concession stand into a dental lab, worked into the night at their alcohol lamps, shaping wax gums and placing artificial teeth, building the temporary “try-in” models for


See more For additional photos from the clinic, go to


washingtonpost.com/health.


patients to test before receiving their permanent dentures. The process was slow and painstaking and the waiting list dishearteningly long. But working steadily, the technicians finished several dozen free dentures. One of the lucky recipients was Grundy, Va., homemaker Teresa Casey, 48, who was left toothless after a six-year strug- gle with cancer and a degener- ative bone disease. Casey had the broken stumps of her teeth extracted last year but could only dream of raising the sever- al hundred dollars she would need to buy dentures. “That’s my whole income,” she said. On Saturday afternoon, Sa-


lem, Va., dental technician Tim Zuber and Bristol, Va., dentist Scott Miller presented her with


a shining set of try-ins. She slipped the pearly artificial teeth into her mouth, and the wages of disease and worry fell away from her face. The hollows disappeared from her cheeks. They handed her a mirror. As she recognized her long-lost self, she began to weep. Then it was Sunday morning. “We are running out of time,” said the dental association’s Dickinson, looking out over the remaining patients. Wallace Huff, a dentist from Blacksburg, Va., was doing a fi- nal consultation. The patient was Lee Rash, a 23-year-old welder, a new father, just laid off from work. Huff showed him his X-ray.


“You’ve got some beautiful bones, a beautiful mouth.” But there was also bad news, the dentist said. A rotting tooth. “If you don’t do something with that soon, it’s going to ab- scess,” Huff told the patient. The young man went and sat down to await his extraction. And Huff paused to gather his thoughts. The dentist said he has been volunteering for 10 years here at Wise.


“I came here because people need help desperately. A lot of people are hopeless. Their teeth are beyond what we can re- store,” he said. Huff hates pulling out teeth. But, he acknowledged, some- times that is the only thing he can do. Then his eyes filled with tears. “We cannot leave these people in pain.” health-science@washpost.com


Mary Otto is a freelance health writer and editor in chief of Street Sense.


the pen from my hand and furi- ously wrote orders to restart the insulin drip immediately and to administer long-acting insulin along with calcium and bicarbon- ate to avoid cardiac arrest from dangerously skewed potassium and acid levels. When she finally departed, all I wanted to do was to crawl under a rock and weep. But there was an intern waiting for guidance and a patient who needed medical care. “Let’s, uh, check the patient’s fluid status,” I stammered, “and then draw another set of labs.” “Got it,” the intern said. Matter-


of-factly he began tearing open gauze pads, labeling test tubes. It was the normalcy of his actions that allowed me to breathe again. That normalcy was an act of com- passion that I’ve never forgotten. We returned to our patient. In two days he was back with the cops. The senior resident graduated and went off to another job. The intern became a fine doctor in pri- vate practice. I continued an aca- demic career at Bellevue. Since that day, I have never failed to in- ject long-acting insulin before stopping an insulin drip. Lesson learned. Doctor reedu-


cated. Near miss caught in time by the system of having more-experi- enced doctors supervise less-ex- perienced doctors.


Case closed. Or should it have been?


Shattering effects Certainly in those days, about


20 years ago, that’s how such near misses and errors were treated. If this happened today, there might be a different ending to the story. The patient would be approached by the medical team and possibly by risk-management personnel, informed of a medical error that had been potentially life-threat- ening, given an apology and told that the hospital and physician accepted full responsibility. It seems entirely obvious: Doc- tors need to apologize for their er- rors, even if the patient didn’t suf- fer irreparable harm. But in the real world of medicine, acknowl- edging responsibility is a dicey proposition. To most physicians it’s tantamount to handing your head to a lawyer on a surgical tray. This fear of lawsuits is so potent that even the most ethical physi- cians want to clam up when issues of medical error arise. Apologies can often be consid-


ered evidence of fault. Depending on the state, there are some pro- tections for apologies that express sympathy, but there is variation as to whether this extends to apolo- gies that invoke responsibility for an error. Typically, the most that doctors can muster is, “I’m so sor- ry this happened.” Such pseudo- apologies are taken to task by Aar- on Lazare in his fascinating book “On Apology” (Oxford University Press, 2004). They are meaning- less, he writes, because they lack the key ingredient of acknowledg- ing responsibility. Lazare notes three emotions that influence the decision to


apologize: empathy, guilt and shame. But then he distinguishes between guilt and shame. Guilt is usually associated with a partic- ular incident, but shame reflects a failure of one’s entire being. Al- though guilt often prods a person to make amends, shame induces a desire to hide. Shame, Lazare writes, is “an emotional reaction to the experi- ence of failing to live up to one’s image of oneself.” Here, I believe, he puts his finger on the precise fi- ber of resistance in doctors. When I think back to that mo- ment in the ER, it was shame that overpowered me. Of course I felt guilty — that was the easy part. But the shame was paralyzing. It was the shame of realizing that I wasn’t who I thought I was. Up until that moment, I’d thought I was a competent, even excellent, doctor. In one crashing moment, that persona shattered to bits.


Addressing shame PETER DAZELEY/GETTY IMAGES


In most other aspects of life, we seem to be able to accept the notion of “good enough.” But there is no room for the good-enough doctor.


One could argue that this is a self-centered way of viewing the episode: how the doctor felt. But it’s precisely the doctor’s emo- tions that stand as the major im- pediment to the full-disclosure policies that are increasingly de- manded.


One has to wonderwhy we doc- tors feel our entire sense of self at risk when we admit error. Per- haps the culture of perfection in medicine fosters a strictly binary analysis: You’re either an excel- lent doctor or a failure. In most other aspects of life, we seem to be


able to accept the notion of “good enough.” But there is no room for the good-enough doctor. Shame worms its way into the


heart and is remembered like few other things. It seems so out of the realm of medical education, fod- der only for those on the couch with their analyst. But it is the ele- phant in the room. No doctor will easily confess to error when a core sense of self is at risk. It’s difficult to develop pol- icy that addresses such a murky and uncomfortable issue. But it wouldn’t hurt for the senior facul- ty to talk publicly to trainees about their own errors and to ad- dress how they dealt with the shame. The very fact of these doc- tors’ continuing to be doctors, de- spite their errors and the atten- dant assaults on their egos, would itself be a potent lesson. Policy efforts have been direct- ed toward proactive settlements with patients, and there is evi- dence that lawsuits are declining. But even if these programs can coax physicians to come forward, the gut instinct to hide an error and defend the inner self will al- ways be the first lynx to pounce on the heart.


health-science@washpost.com


Ofri (www.danielleofri.com) is an attending physician at Bellevue Hospital and the editor in chief of the Bellevue Literary Review. This essay, excerpted from August’s edition of Health Affairs, is avail- able at http://content.healthaffairs. org/cgi/content/full/29/8/1549.


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