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So What Do You Wanna Do About It?

November 5, 2010 by Leave a Comment

“Overnight, Mrs. Blake had 650 cc of emesis,” I reported to my senior resident.

“So what do you wanna do about it,” he asked me.

Unprepared for the question, I paused. I was expecting him to tell me what he wanted to do about it. I’m still trying to get used to this whole 3rd-year-medical-student-thing.

As I continue in my training, I have to transition from someone who collects data to someone who interprets data and comes up with a plan for what to do next. Anyone can collect data. But I’m going to be a doctor. At least that’s what my senior resident said to me.

Fine. I have to learn to do something about the data I collect. It’s tough, though. I don’t want to do something wrong. It’s comfortable to “just” collect data without having to do something with it.

I suppose it is fitting, then, that the last two years of medical school revolve around the question of “what is the next step in management?” This is in contrast to the emphasis in the first two years where the question that haunts medical students is “what is the diagnosis?”

Change is hard. But change, I must.

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Jumping Out Of Bed

October 31, 2010 by Leave a Comment

I remember one occasion when I was sitting in on a patient visit. I was there just as an observer. The attending was giving his elderly patient instructions about a new medication he was about to receive. The conversation went something like this:

Doctor: Make sure you don’t jump out of bed. Go slow; take your time. Sit up, get your bearings, and then stand.

Patient: Don’t worry. I haven’t jumped out of bed since I was in my 20s. And that was because her husband came home!

 
I don’t know if he was being serious or if it was only a joke. But I liked that patient.

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What’s your name? What’s your number?

September 26, 2010 by 1 Comment

Even as a medical student, one meets and interacts with enough patients that it is difficult to keep the details of their lives straight. But if there are two things that you should remember about each patient before seeing them, it is their name and their number. And by number, I don’t mean their digits.

Most patients are pretty reasonable about understanding that people in the hospital or clinic deal with so many patients that they don’t care if you forget the name of their dog or their third cousin’s limping poodle. They do, though, at least hope that you can remember their name when you walk into their room. After all, when entering a room, one often does have access to the patient’s chart. So putting in the little effort it takes to get the name correct is something everyone appreciates — even the little ones.

I remember one time when I was on my Pediatrics rotation. I was on the In-Patient portion of the rotation, which means I was seeing patients who were admitted to the hospital and were staying there for their treatment. As is the custom of many a medical student, my white coat pockets were filled with papers. One of them had the name and room number of the patient I was going in to see.

I glanced at the name and room number and started off to see the patient. I’ll call him Joey. Joey had been in the hospital for about half a week and I had seen him every morning at around 7 AM. This day, however, I was in a hurry. I needed to see him and do a quick check and then get over to a morning meeting. My mind was racing about the things I needed to do after my visit.

“Hey Chris,” I said as I walked in. Joey looked at me silently. There was no correction. Perhaps he didn’t have time to correct me. I quickly corrected myself and said “Joey.” But the damage had been done.

He wasn’t as happy as usual during my visit that morning. This was probably due to the fact that he was medically worse that day than the day before. But I can’t help but think that the fact that someone totally forgot his name played some part in him not even smiling during that visit.

I felt bad about my mistake. I don’t do much as a medical student. The most I could have done was to get my patient’s name right. All I needed to do was to look at my sheet as I was walking in the room. It probably won’t be the last time I slip up like this and say the wrong name. But now, because of Joey, I pause before entering a room to make sure I read the name correctly.

The second fact about a person that I think one should remember is their age. A 53 year old woman might be happy when you say that she is 43, but it does her no good for you to treat her as a 43 year old. The screening and prevention that a 53 year old needs is different than the screening and prevention a 43 year old would need. Knowing someone’s age is not just a nice thing to do, it helps in their care.

There was one time when I was doing a complete physical for a young man. As I got to his social history I asked him about his smoking, alcohol and drug use. He denied all three. Never smoked. Never did drugs. When I asked about alcohol he said no at first. But then admitted to having some alcohol a couple months ago. And it was at home, he added.

I was really confused. It seemed like there was some guilt in this admission. Most people I asked freely admitted to drinking multiple drinks on the weekend. I wondered if there was some sort of problem. After all, guilt about alcohol use is one of the things used to screen for alcohol abuse. I considered pressing the issue further to investigate the possibility.

Then I realized the guy was under 21 — the legal drinking age. He was slow to admit one drink a couple months ago because he shouldn’t have any legal means of obtaining alcohol in California. If I had remembered his age, I would have known that the guilt I perceived was not because he was having an alcohol abuse problem, but because he had just admitted to being a minor who had one drink. At home. A few months ago.

So the next time you enter a room, just sing to yourself, “What’s your name? What’s your number?” And it’ll all be easy from there — hopefully.

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The Humanity of Medicine

September 21, 2010 by 3 Comments

The following is a post I wrote for Medscape. It was published on their The Differential blog on January 30, 2009.

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I received an email this week regarding an essay contest. The first place winner would receive $1000 and the top three essays would be published in the AAMC’s Academic Medicine. (This is the Gold Foundation’s 2009 Humanism in Medicine Essay Contest.) This year’s essay is to be a reflection on the following quote by Anatole Broyard:

To most physicians, my illness is a routine incident in their rounds, while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity.

 

As I read that quote in the email I paused. I thought it simple, yet profound. And although I deleted the email, thinking my chances of winning an essay contest too slim to bother with, I quickly copied the quote and added it to my growing collection (a 41-page Word document consisting of just over 14,000 words).

The idea behind this quote is simple, really. It challenges those of us in (and going into) the medical field to remember what it feels like to be on the other end of the stethoscope — to remember that there is a person and not just a pathogen infecting a host. I remember a course in my freshman year called Understanding Your Patient. The course was not that hard. We talked about teaming with our patients. We talked about how to bring up tough subjects. We tried to learn how to step into their world.

Later in the sophomore year I took another course called Art of Integrative Care. This class challenged us to go deeper into the lives of our patients. The entire quarter was spent investigating and discussing how to practice Whole Person Care by addressing the spiritual health of a patient while we cared for their physical well-being. One assignment for this class sent us into the hospital to interview a patient. We weren’t there to investigate their physical ailment. We were there to get to know the patient, how they were coping with illness, where they found strength, and how (if at all) the illness had affected their belief system. How much more personal can a healthcare provider get than when talking to a patient about their fears and insecurities, their beliefs and doubts, about why bad things happen, and their hopes and their dreams?

What struck me is that this course just ended one month ago, yet the ideas I heard have somehow slipped away from the surface. I attended clinic today at a Pediatrics office. Thinking back, I remember times when I didn’t even bother to consider what the patient was feeling. I walked into the room following the attending, smiled and said hello as I was introduced as the medical student, and listened intently to the patient (or the patient’s mother) as the symptoms and complaints were recalled. My mind raced to form a differential in case I would be asked a question regarding the patient. In that frenzy it became all about the disease. I was desperately intent on meeting and beating the microbe.

But there were also times when the attending walked out of the room to go get something. During one of those times I found myself looking across the room into the eyes of a young patient and her mother. Maybe it was just to avoid an awkward silence. Maybe I didn’t want them to think me totally inept or socially retarded. Or maybe it was that a part of me wanted to connect with the people on the “other side.” Regardless of the reason I, the self-proclaimed king of introverts, spoke up. I engaged the little patient. We talked. She laughed. Her mother smiled. She told me that her mother had lots of sisters but she only liked one. She giggled. Her mother laughed. I chuckled.

We all left the room knowing what the diagnosis was and what the treatment would be. More importantly, I left the room knowing that I had met the patient and not just the disease.

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On the Wards – A Book and Its Cover

September 20, 2010 by 1 Comment

One isn’t supposed to judge a book by it’s cover. Everyone knows that. Kids learn this saying in elementary school. But it’s just too easy to do so. In my opinion, this is because we humans are “lumpers.” That’s how we learn. We lump things that are similar into categories and when we encounter something new, we try to see which category it best fits into. Or perhaps I am a lumper and I am lumping you all into the same category as I am.

But back to books and their covers. I remember being on call while assigned to the Pediatrics service one night. As I pulled my vibrating pager off my hip and read the message, I learned that I would be going down to the Emergency Department (ED) to do an admission. There was a young girl who was presenting with what seemed to be an asthma exacerbation. I went into the resident call room, discussed what I needed to do with the senior resident on call, and headed down 6 floors to the ED. I chose the elevator, of course.

In the room, I saw the little girl. She was sitting on her bed playing with an older relative while a TV program ran in the background; well maybe I should say it ran in the foreground because it was pretty loud.

I turned to the child’s father. Since the child was in no apparent distress — she was, after all, playful and breathing well — I began taking the history from him. Her father, whom I will just refer to as “Dad” for brevity, remained in the chair, his eyes affixed to the television.

We talked. I asked. He answered. Our eyes rarely made contact. Most of the time Dad kept his head tilted upwards towards TV set. He didn’t even bother turning it down.

I felt like he was disconnected — like he didn’t really care or feel this was a big deal. I didn’t make this conclusion based on his continued TV watching alone. Other things felt odd. Details were sketchy. Some of my questions regarding the timeline of the girl’s asthma just didn’t make sense. I wondered to myself if he was actually very involved his child’s care. But I plugged on through the interview like a good 3rd year medical student.

At the end, because I had forgotten to do it earlier, I asked him if his daughter had any exposure to tobacco smoke at home. “Yes,” he answered.

“Who smokes,” I asked.

“Me,” came the reply. He only momentarily looked at me before averting his gaze.

I said alright and left it at that. I was eager to leave. I was tired of dealing with a parent who obviously didn’t appreciate the significance of being admitted into the hospital from the ED. Did I bother suggesting that his daughter should avoid 2nd hand smoke? Did I take time to suggest he quit? Did I offer help?

No. I left.

A couple days passed and I was sitting in the Physician’s Workroom with other students and residents working on our progress notes. Our attending came in and announced that she had talked to Dad about his smoking and he had expressed interest in quitting. One of us (the resident or I) would be in charge of getting Dad in touch with the tobacco cessation program people.

I was stunned. Dad wanted to quit?!? The same Dad that seemed more interested in the television show than his daughter’s admission?

It was something I should have caught. It was something I should have offered. But to me, he looked like he wouldn’t be interested. And that was my mistake.

“They” say never to judge a book by its cover. I’m inclined to say that this is one lesson I’m still trying to learn.

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On The Wards – PM&R

August 31, 2010 by 3 Comments

For the past week and a half I have been on my 3rd year elective. At LLU, we do a 2 week elective after our Pediatric rotation. It has been interesting. They told us to use the elective to help us to either rule in or to rule out a specialty we are considering.

I ranked Physical Medicine & Rehabilitation (PM&R) as my first choice and was glad when I found out I got it. I chose it because I had heard many people say that it is a good specialty to go into: decent pay & good lifestyle. But I really had no idea what PM&R doctors did.

With my 2 weeks rotating through the PM&R service I hoped tho learn more about what these doctors actually do and explore the specialty as best I could. I’ve learned that these PM&R doctors are called physiatrists and their goal is to improve the quality of life and the function of their patients. Within this specialty doctors manage pain, assist in regaining physical function, deal with amputees, treat spinal injuries, etc. It is a huge field.

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Today I saw a stroke patient. I’ll call her Sharon. Sharon has been in the recovery unit for quite some time. The thing that stuck out to me was that her left side was extremely weak due to the stroke. However, she insisted that it had always been that way. To her, there was no change in her physical abilities and she couldn’t understand why she was still being kept in the rehab facility.

I’d heard about hemineglect before but this was the first time for me seeing it live. And it was very odd to see.

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PM&R doctors also do EMGs like neurologists. I got to chance to observe during one day of EMG clinic. The whole ordeal looked quite uncomfortable. After the first patient finished, one of the medical students asked the attending if he could explain a little bit about EMGs. He took us back into the room and proceeded to perform an EMG on himself.

EMG
He took it like a champ. While the patients were squirming and moaning with pain, the attending just fiddled with that needle in his muscle. So I snuck this picture in. If you click on it, a larger version should pop up and you might be able to see the needle.

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Overall, it’s been a good experience. I’m glad I got a chance to see the wide variety of things that happens within the PM&R specialty. At this point, it is still on my list of possibilities.

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Any other symptoms?

August 20, 2010 by 1 Comment

OSCEs are a great way to test students. Every student sees the same “patient.” The actor might be different, but the case they are given to memorize and act out is the same. It allows for standardization and makes evaluating students all the more easier because everyone is on the same playing field.

The problem is that OSCE patients are there to test us — not figure out what is wrong and get treated. And since the goal of the “patient” is different, they act differently than real ones.

For example, when I have seen real patients who come in sick, I often need to slow them down because they are just spouting off everything under the sun that is wrong with them or their child. So a mother bringing a child in with a chief complaint of diarrhea will tell you that the diarrhea started at such and such a time and the kid also had a fever and threw up a couple times, etc.

An OSCE mother will tell you that the kid is suffering from diarrhea. And when you ask if the kid has any other symptoms, it is likely that she will reply, “No.”

I get why a fake patient does this. They are there for our practice and for us to be evaluated on our clinical skills. We should be pressing for specific symptoms once we have an idea of the diagnosis. So after taking the history we have to go over the “Review of Systems” and ask specifically for different symptoms (i.e., vomiting, diarrhea, fever, headache, etc.).

But it just feels like I’m playing a game, or that my “patient” really isn’t all that interested. Because as a parent, wouldn’t you be listing off all of the symptoms you have noticed if it is as obvious as a fever you personally measured?

And now this rant ends.

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