Monday, June 29, 2009

Remembering the Patient Perspective

Being a med student puts you in the unique position of understanding both the patient's side and the physician's side of a hospital visit. We are not yet comfortable enough with the medicine to think that the diagnosis, treatment, or prognosis are routine everyday occurrences, but we understand some of the physiology and consequences of illnesses.

This perspective often allows us to see flaws in the way physicians, who have much more experience than we do, interact with patients. Physician experience breeds complacency as broken bones, surgery, and even death become "part of the job". On top of that, many doctors are overworked, exhausted, and running on very few hours of sleep. With such a combination of exhaustion and fatigue, it is not surprising that the quality of a physician's bedside manner may be reduced. However, I think there is a basic standard that must always be met.

Yesterday, I was in the emergency room with a friend who had injured her shoulder. She was in pain and very concerned that her shoulder may be broken. The emergency room physician that came to see her was very direct and concise. He did not indulge her in any small talk and, thus, did not build any rapport with her. When he began to examine her, he pulled the chair I was reaching for away from me without saying a word, so that he could use it himself. Now, this physician was not particularly friendly, but I don't feel that he did anything wrong in this physician-patient interaction (even though the guy stole my chair!). He was efficient, he got the job done, he explained to his patient everything that he was doing to her and he also explained what she should expect to happen during her next hour in the hospital.

The next physician that saw her was an orthopedic surgeon. He introduced himself, explained to the patient that she had broken her clavicle, and presented her options. She could elect to have surgery to repair the bone immediately, which would mean she would have to stay in the hospital for the next day or two, or she could wait to see if the bone healed on its own over the next two months. If the clavicle proved unable to heal on its own, she would have to have the surgery anyways. Due to hospital policy, if she wanted to have the surgery immediately she had to decide while she was in the hospital, otherwise, she would have to wait the two months.

This orthopedic surgeon did the bare minimum that was expected of him. He answered all of the questions that were asked; however, he did not even attempt to convey any additional information that could be important to the decision at hand. I think he should have mentioned how either decision would affect the range of motion in the shoulder, any potential complications if she chose to wait two months and found she still needed the surgery, or how her short term quality of life would be affected if she chose to wait two months. He did answer all of these questions when asked, but what if they had not been asked? It's hard to make an informed decision if you aren't informed! While talking to me, she mentioned several times how she did not like the idea of having a foreign object in her body. He just sat there pretending he didn't hear anything, instead of providing his insight as an orthopedic surgeon and perhaps mentioning the evidence based data that supports inserting a metal plate into a person's body.

Worse of all, he kept mentioning how he was in a hurry because he was "off the clock". He explained that he started his shift at 1:00 pm, it was 12:00 am at the time, and he needed to get home to sleep because he had to be back at the hospital at 7:00 am. He pushed for a decision over and over again saying things like, "once I'm done this paper work you've got to decide", "we're on my time, I need to go home", and "listen ma'am, I don't know what is taking you so long". In short, the guy was douche. For him, surgery to repair a broken clavicle might be as normal as warming up leftovers for dinner, but for the patient, this was the first broken bone she had experienced, it was a big deal. Pushing her to make a decision in five minutes is not only incosiderate, it is unethical. He hadn't taken the time to teach her enough about the surgery to consider her decision informed.

I understand that he was tired, that he wanted to go home, and that he doesn't control hospital policy, but all he needed to do was take off his douche-bag-doctor-hat and wear his normal-human-being-hat to see that he should have explained everything. All it would have taken was a "look, I'm very sorry, but hospital policy states you have to give me your answer before you leave and unfortunately, I'm at the end of my shift. I've been here since 1:00 in the afternoon and I'm due back at 7:00 this morning, so I need to go home and get some sleep to be able to do my job properly. I really do apologize, but this means you are going to have to make a decision in the next ten minutes, which is really tough. Is there anything I can do to make that easier?"

If he would have spoken like that his patient would have been more comfortable with him and probably trusted him a hell of a lot more. In fact, she probably would have agreed to allow him to perform the surgery on her. Instead she thought he was a jerk and didn't want him to touch her, a response I'm sure he is used to from his experiences clubbing at a younger age...

Saturday, June 27, 2009

Smoking Leads to Cancer?!

Sometimes med students, physicians, and everyone else involved in the health care industry forget that our knowledge about health and medicine isn't all common knowledge that we can expect everyone to know. Apparently, not everyone knows that St. John's Wort is actually a medication and it has many drug interactions you need to be aware about before you fill a prescription if you are taking St. John's Wort. However, there are some things that I think the general public should be expected to know. One of those things is that smoking leads to cancer! Seriously, people NEED to know this! Lung cancer is a terrible way to die and you need to be aware that smoking greatly increases your likelihood of lung cancer. If people knowingly risk lung cancer and continue to smoke, that's one thing...but people who start, or advocate, smoking without knowing how fatal smoking can be...that really shouldn't happen in this day and age!

Wednesday, June 24, 2009

Calling Out the Boy Who Cried Wolf

Munchausen syndrome by proxy is a scary form of Munchausen syndrome. In Munchausen's the patient fakes an illness to get attention from physicians. In Munchausen's by proxy, a person, usually a parent or caregiver, makes a patient, usually a child, sick or injured to get attention from physicians. The parent or caregiver can even fabricate the child's illness, making the child believe that he is sick and that he needs to see a doctor when he is actually completely healthy.

This is a difficult diagnosis to make because if it is incorrect, the child will not be getting the treatment that he needs.

Sunday, June 21, 2009

Admitting Ignorance is OK

It is not OK for a patient to have sinus congestion for an entire year. It is not normal for a patient to develop a recurring fever for a day or two almost every month. When these symptoms occur simultaneously with the onset of joint pain, maybe there is something actually wrong with your patient. I don't know, maybe your patient is actually ill? Running a gamut of tests that return negative results and then telling your patient, that it is just her allergies, is not proper patient care. She has had her allergies for her entire life and she has only had the aforementioned symptoms for the past year. Something doesn't add up here.

I think doctors should be comfortable with saying that they do not know what is going on. Referring a patient to a different specialist or to another colleague for a second opinion doesn't mean you are a bad physician; it just means you want someone with a different perspective and a different set of experiences to take a look at your patient and help you figure out the problem. That is how medicine is supposed to be practiced.

Maybe you're right, maybe her allergies have just progressed and the symptoms have become worse over the past year. Even if that is the case, you should probably tell your patient why you are not modifying her allergy medication and its dose because, otherwise, it seems like you are saying her allergies are getting worse and she just has to live with that. Maybe that is also true, and there is nothing medicine can do for her new symptoms, but TELL her that, don't make her guess. I feel like I'm just asking for basic patient care that every physician should seems to ME like all of this is just common sense.

In the end, your patient is confused, suffering, and thinks her doctor is incompetent and a bit of a jerk (the latter two points may or may not be true...I have no idea, I've never met you). She is so desperate for decent medical advice she has resorted to asking a first year student what she should do and then exclaimed that I gave her better advice than you ever did. That is embarrassing. Relatively speaking, that is like a dog providing better relationship advice than your best friend...seriously, us first years are idiots (for now...).

Wednesday, June 17, 2009

Do Patients Really Worry About How They Are Addressed?

Throughout our first year, we have been taught asking a patient how they would like to be addressed is an ESSENTIAL component to the beginning of a medical interview. For instance, a normal opening to an initial interview with a patient might be: Hi John Doe, my name is William Abbott, I'm a medical student and I've been asked to interview you, is it alright if I call you John, or would you prefer Mr. Doe?

Do patients really care whether you call them by their first name or their last name? The last time I remember anyone being upset with me for using their first name was when I was in grade 3 and I learned my teacher actually had a first name, so I couldn't help but use it. I would also think that a patient would correct me if they didn't like how I was addressing them. I really don't see much value in asking a patient how they would prefer to be addressed, not that it is too much work or anything, I just don't like doing pointless things. However, the faculty REPEATEDLY demands that we do ask patient's how they prefer to be addressed. It is even incorporated into both of our first year clinical exam evaluations. Hopefully one day I'll understand what value this brings to my clinical interview.

P.S. Next time you're in the hospital...ask to be addressed as Batman, at the very least you'll give your doctor/resident/med student a good laugh. Although, I probably wouldn't do that if the physicians suspect you may have a psychiatric illness.

Tuesday, June 16, 2009

Researchers Should Learn How To Program

Throughout most of my first year in medical school, and by most I mean the entire time, my background in engineering was useless. Sure, I could figure out how to plot the inverse of a graph without breaking a sweat, but surprisingly, that isn't an important skill to have as a doctor...doesn't really help with picking up the ladies either, seriously, Dr. Madden is a liar!

Anyways, this summer I'm doing research and I've finally been able to take advantage of my background in electrical engineering. I've found my experience in programming to be priceless. In our lab we collect our data in excel spreadsheets and then analyze them. Excel, and most other Microsoft Office products, have a scripting language called VBA. VBA is an easy language to learn, particularly if you have programmed or scripted in another language before. Using VBA, I am able to automate data analysis. For example, instead of having to calculate the mean of a column, I can write a script that will do it for me. Not that impressive when you look at a simple example like that, but you can imagine that if you have ten thousand columns per spreadsheet and you have 500 spreadsheets, then it would be nice to be able to write a ten line script just once to be able to calculate all the column means you need.

Anyways, being able to automate the analyses of the excel data has been incredibly valuable. I spent maybe a day writing scripts, but I will save at least two weeks in the end because the scripts will take me about two minutes to analyze the data collected from each patient.

Automating analyses can be a huge time saver. The time you invest in learning how to script will payoff in the end, especially if you find that you can reuse parts of your scripts in multiple studies (which is often the case).

Friday, June 12, 2009

Med School Finals vs. Undergraduate Finals

Practically everyone knows that med school is difficult and that the exams are fairly intense. People even joke about how med students become intimately attached to caffeine during exam season just to survive (funny because it's true I guess...).

One of the first things you should realize as a med student is that these exams are different from any exams you have taken before in undergrad. I did my undergraduate degree in engineering, another degree that is universally considered to be difficult, but even though I had up to 9 courses in a term, those exams were much easier. The difficulty in medical school exams comes from the amount of content, not necessarily the difficulty of the material. The key difference from undergrad is that you can review an entire undergrad class in 3 days if you have kept up throughout the year and you can buckle down and focus during crunch time. After those 3 days, you can known EVERYTHING that you are expected to know for that course.

In med school, you can spend three weeks, theoretically, studying for a single course and still not memorize everything you need to know (I say theoretically because you also have several other courses you need to study for at the same time so you can't actually devote three weeks to a single course). The best thing you can do for yourself as a med student is to accept that you won't know every detail of every subject that you can be tested on. Coming to terms with this fact will help you study effectively without stressing out. Many of our exams are multiple choice, so if you focus on understanding basic principles you can often do a good job of narrowing down the correct answers.