Archive for the 'Medical Musings' category

Listening

Nov 12 2010 Published by under Medical Musings, Medicine

The exam room is a sacred space, one in which people  bare themselves both emotionally and sartorially.  It is a secular confessional, a chapel for the examination of sinew and sin, pain and disbelief, intimate failings and mortal fears.  Sometimes it is a place to share joy, but more often it is a place to explain one's physical and emotional imperfections in hope that someone will hear and understand in a concrete way.

The interaction between patient and doctor isn't that well-studied.  There are strong suggestions in the literature that the more we allow our patients to set their own agendas and to answer open-ended questions completely, the more likely the patient's problems are to be addressed.   But what takes place in the exam room?  What is it that allows a patient to bare soul and body and allows a physician to really understand what a patient is saying and feeling?

One popular notion is that empathy, like good looks, is something some people just happen to have. I perceive myself as being an empathic physician (which of course may not be entirely true) and I'm curious what makes me so.  When I think of my own interactions with patients  I notice a few things.  In addition to standard listening techniques, I try to imagine how a patient feels---viscerally, literally, physically.  If a patient describes chest pain, I try to imagine what it feels like as described.  I try to imagine the emotions they felt when they had it, the fear, the uncertainty.  And I try to gauge the patient's reactions to my reactions.  My facial expressions and posture can promote fear or give comfort.  If I want the patient to continue to be concerned, my words and actions can purposely fail to give them complete reassurance (always telling them, though, that we will do whatever we must to get to the bottom of things).

I don't presume that this always works out for me and my patients---this is necessarily an empiric exercise, a muddy one that goes on from minute to minute and is measured in subtleties.  I'm also not sure how deeply this should be studied formally.  While I'm certain that empathy can be taught (or at least a reasonable facsimile of empathy), I'm also certain that there is not one sort of "empathy" that works for all doctors and patients.  There will always be some mystery in the exam room, and that is what makes it sacred.

5 responses so far

When do you move from living to dying?

Nov 03 2010 Published by under Medical Musings, Medicine

As physicians, we're pretty good at diagnosis. This hasn't always been the case. Diagnosis takes not only excellent clinical skills, but a thorough knowledge of the causes and manifestations of human disease, good diagnostic equipment, and an understanding of what these skills and tools can and cannot tell you. But while our diagnostic skills have improved, prognosis has often eluded us.

And yet, what could be more important that prognosis? What could be more important than knowing the probable course of your illness, and how long it may take to kill or maim you? As I sit typing, comfortable in my office chair, physically limited only by my own lack of exercise and poor eating habits, someone is laying in a hospital bed hurting and afraid. He is at a very uncertain time in his young life, and no one can tell him with any certainty what will come next or when.  He needs to know his prognosis.

For reasons obvious and otherwise, age affects our approach to treatment. There are probably value judgments involved, but from a practical standpoint, there are things a young body can tolerate that would kill someone older. Prognosis may often elude us, but we know that, in general, an 80 year old is closer to death than a 40 year old. In general. And in general, a 40 year old may be able and willing to tolerate treatments that would kill an older patient.

Knowing the likely course of an illness (not its natural history, but its real-world course when treated) is important not only for ordering one's affairs but for planning further treatment. If an elderly man breaks a hip, we have to weigh very practical considerations---hip fractures often lead to death due to the complications of immobility, but in some patients, the surgery can be very risky. In a young patient with cancer, there is often more room to be aggressive, but how do we know when to advise someone to stop?  When do we tell a patient, "the disease is winning, we can't stop it, but we can treat the symptoms?"

Sometimes, after a crappy diagnosis, a patient may sign on with hospice and go gently, comfortably, and surrounded by family.  Sometimes they feel a need to "fight", however they may understand that word.  But if we are going to help someone fight a dismal prognosis, we'd better be prepared to tell them exactly what that may entail.  For example, if I diagnose a young man with widely metastatic colon cancer, one that appears to be hopelessly* advanced, I know that the oncologist will offer them chemotherapy.  Depending on the clinical situation, it may be that chemotherapy could extend his life for several months.  The patient must be given a choice (but often isn't): should he focus on symptom management in his last weeks-to-months, or should he focus on extending his life?  These two goals are often mutually incompatible.   It is my belief---one with out the support of empiric data---that patients are not often given enough information to make this choice.  They are not told that the price of extending life by a few months may be horrible pain, a pain that makes them choose between being completely snowed by narcotics or being in agony.  They may not be told that blockages in the colon may cause them to vomit their own feces, and that they may need surgery so that the colon drains through a hole or a tube rather than through their mouth.  They may not be told that infections, pain, and delirium may keep them in the hospital and prevent them from having any meaningful interaction with their family.

I don't mean this post to be hopeless, to imply that a terrible diagnosis leaves a person with a binary choice between suffering and death.  But we physicians must be willing to tell patients the entire truth, and patients must be willing to understand that truth is not meant to destroy hope, but that hope built on a lie isn't hope at all.

________________________

*Hope is a tricky concept.  There is always hope, but as doctors we must temper hope with realism, and tell patients which goals they can "hope" to achieve.  These goals may be control of symptoms rather than control of disease.

14 responses so far

When did you really feel like a doctor?

Oct 21 2010 Published by under Medical Musings, Medicine

The Doctor, Samuel Luke Fildes (1843-1927)

Yesterday on Twitter, my friend and colleague Dr. Isis noted that she still gets a sense of surprise when she sees "Dr" next to her name in an email.  She, Alex Wild, and I wondered what are the experiences that really make you feel like a doctor (in this case, PhD or medical doctor).  So I started wondering: what are the experiences that made me really feel like a doctor? Was it the white coat ceremony?  Dissecting a cadaver? Wearing scrubs and a stethoscope around my neck?  All of those are important steps, and important memories for me.  But as I thought about it, I was taken back to a particular night in a particular place.

My residency program had a night float rotation.  Three senior residents would be in the hospital from 11pm until 7am (more or less), each covering a different set of patients.  We would run cardiac arrests, admit new patients, and put out various (metaphorical) fires.  And we would pronounce patients dead.  Each of us shared the duty, on a nightly rotation, of covering the inpatient hospice service.  On one of my first night float calls, my pager went off, directing me to call the hospice unit.  They asked me to come down and pronounce someone dead.  I walked down the hall (no hurry, right?), got on an elevator, walked down another hall and into the calm, well-appointed unit, with its gentle lighting, living room couches, aquarium (at least, I think there was an aquarium).  The nurses directed me to a corner room.  The lights were low when I walked in, and a man was laying in the bed.   His color was---wrong.  Everything was wrong.  I walked over and tried to wake him up, shaking him and calling his name.  I took out a penlight and lifted open an eyelid, my fingers resting on his cold, sweaty brow.  His pupils didn't react.  I placed my stethoscope on his chest and watched and listened for a long time.  There were no breath sounds, no heart tones.  He was most certainly dead.  I called the attending physician and the family, waking them both, and sat down to do my part of the "death kit", which included the death certificate.  After a few jests with the nurses, I walked back out into the harsher light of the living.

I'd never felt more like a doctor than I did that night.

6 responses so far

Time well spent

Aug 04 2010 Published by under Cancer, Medical Musings

This was first published April 26th, 2010.  While I'm Up North, I'll be reprising some of my favorite pieces. Thanks for your patience.  --PalMD.

A few years ago I was walking through a local mall with my daughter and saw a kid about her age wearing a backpack and holding hands with a young woman. He was a gorgeous little boy, with black hair and huge black eyes. His eyes reminded me of my daughter's. There was a name tag on the backpack. The last name was unusual but one that I recognized as that of a guy I grew up with---and this little boy looked just like him.

So I politely asked the woman if she was D's wife. She laughed and introduced herself as a family friend. My friend D and his wife were in California getting her cancer treatment.

I'd heard that D's wife had been diagnosed with cancer shortly after giving birth, but I hadn't really seen D in years. He was one of the nice kids in the neighborhood, brilliant but not overly nerdy, kind, and not into torturing other kids. I figured he must have married a wonderful woman. And I was right.

I'm not sure how we all became friends, but somehow we did. My wife and his hit it off immediately. She was never "our friend with cancer" but just our friend. Still, there were reminders that she wasn't entirely well. A couple of years ago, she started to experience a cough and some pain in her side. Despite this, we went to a side-splittingly funny movie where she alternately laughed and cried. We found out a little later that she had broken a rib.

My friend has been in the hospital for a while. It's a long story, and not a good one, so we'll leave that be, but it's given me an opportunity to spend a lot of time with her. And while I'd rather hang out at their pool with the kids eating Chinese food, this time together has been remarkable.

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10 responses so far

"Nobody knows, the trouble I've seen..."

Jan 14 2010 Published by under Medical Musings, Medicine

The great Dr. Sandy Templeton once asked his pathology class, "Why do people go to the doctor?" People came up with all sorts of responses, but to each he gave his best British, "No, no, no, no!" Then he would tell us, "They come to the doctor because they don't feel well and they want you to make it better!"
So obvious. So simple. And yet, so complicated.
As physicians, we have a number of ways of helping patients, only some of which make the patient feel better. Primary and secondary prevention of disease don't necessarily make people feel better in the short run, so they can be unsatisfying. And many ways of "not feeling well" aren't easily fixed. People have complicated lives, lives full of stress, lives full of poor sleep, lives full of inactivity. There is no magic pill to make most people feel better.
Sure, sometimes we get lucky. I had a patient a couple of years ago who came in with the common complaints of fatigue, weight gain, etc., and as usual, I checked her thyroid---and not as usual, her thyroid was significantly low. Not long after I started her on thyroid hormone replacement, she felt considerably better.
Unfortunately, most people who feel generally unwell don't have a simple physiologic problem such as a hormone deficiency. We can still help them by being good listeners and giving them good health advice, but that only goes so far.
In general, we fail to make everything all better all the time. This failure is accepted by most patients, as most people know that being human comes with various imperfections. But some people are not satisfied to know that feeling lousy can be normal. They will go from doctor to doctor, looking for "the answer." Sometimes they find it. The third or fourth doctor may be the first one to finally diagnose the hypothyroidism, or celiac disease, or diabetes, but often the doctors say the same thing over and over---reduce your stress, eat better, exercise more. Take better care of yourself.
Which is, of course, not always possible.
Some people will continue to go from doctor to doctor until they finally land at the door of someone with all the answers. This person may have a different way of doing things, a way that somehow has escaped all the previous doctors. Often, a patient is just happy that someone finally listens, finally appears to understand their suffering.
Real doctors often give difficult news. Sometimes the answer to someone's suffering is, "I'm so sorry. I'll do whatever I can to help you through this." Sometimes it's tempting to give good news, whether or not it's warranted. It can be very tempting to say to a patient, "You know, all of your troubles are due to a low selenium level, and if only your other doctors had checked it, you would have felt better by now. It's a good thing you came to me. Here's some selenium."
But offering good news without evidence to back it up is self-serving and cruel. To elevate oneself as the only doctor with all the answers is dangerous, not least because you might start to believe it. And the moment you believe in your own infallibility is the moment you lose your way and put your patients at risk.

79 responses so far

Service

Oct 27 2009 Published by under Medical Musings, Medicine

The young resident presented the patient in the usual dry terms we use for such things.
"The patient is a 42 year old woman recently hospitalized for cirrhosis due to alcohol use. Her cirrhosis has been complicated by esophageal varices, encephalopathy, and refractory ascites."
In other words, the woman has drunk herself nearly to death.
"Is she still drinking?" I asked.
"She says not. She says she stopped about six months ago when she first got sick."
"What did GI say? Did they refer her for transplant evaluation?"
"No," she said, a bit disappointedly, "they said she wasn't a candidate."

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10 responses so far

How to survive your hospital stay

Oct 16 2009 Published by under Medical Musings, Medicine

Recent discussions around here reminded me that it's time again to talk about what it's like to be in a hospital, and how to survive the experience.

But first, as we move into the last two weeks of our very-successful Donors Choose challenge, I'd like to invite health care professionals in particular to participate. Gifts are tax-deductible and help out needy Michigan school kids with specific, vetted projects that are often useful for several years.

Micro-donation is a great way to go. While big gifts are great, even a couple of bucks add up quickly, especially on challenges with Gates Foundation matching.

The economy has hit health care hard, and many of us in health care have seen our patients disappear and our own incomes drop. But most of us are doing better than the families of these kids. If a couple of bucks helps even one kid get excited about learning and some day join our ranks, it's worth it. To finish funding my original projects will only cost about $1000.00, an easy goal to make by the end of the month. So c'mon docs and nurses. C'mon CRNAs and EMTs. Fork over a couple of bucks and help the kids. OK, end of digression.

Being ill is a profoundly humbling experience. Even minor illnesses change the way we think, not just about mortality and finances, and other "big things", but it changes our ability to think. Let's take a relatively mild illness as an example. Kidney stones are horribly painful, but rarely fatal. The pain is exquisite, and impairs one's ability to reason. The medication used to treat the pain further impairs one's memory and judgment. If a little IV fluid and some hydromorphone fixes everything, fine. But let's say the urologist is asking you whether you want to go through with a stent, a stone-removal via basket, a lithotripsy, or something else. Trying to parse through this complex information when in pain and stoned on Dilaudid is a challenge.

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18 responses so far

Thanks, Doc

Aug 20 2009 Published by under Medical Musings, Medicine

I was one of those crazy folks who loved medical school---not just the clinical years, but the pre-clinical sciences as well. The transition from pre-clinical to clinical can be rather unnerving (picture learning how to do a pelvic exam on paid models). One of my first clinical experiences was in our physical exam class. Much of this was done on each other (not the pelvics), but we were also paired with attending physicians who would take us to see---gasp!---actual patients.

The guy I was paired with was old---impossibly old. I wondered to myself if he still had a jar of leeches in his office. But he wore medicine like an old, comfortable coat. I, on the other had, was wearing my short white coat for the first time, and feeling particularly clueless. When we were on our way to see some of his hospitalized patients, he said we had to stop by the ER to see a patient of his---the ER! Cool!
The one thing I remember was the EKG. He picked it up, glanced at the red and white paper with the 12 separate tracing on it, and said, "yeah, he's probably fine." He didn't teach me to read EKGs. But he showed me that some day I would be able to glance at one for a moment and pronounce someone "OK" or "not OK". It was magic.

Anyway, my alumni newsletter arrived in my inbox today. "Dr. Paul Winter was a senior attending physician and associate professor of medicine emeritus...He is survived by..."

Thanks, Dr. Winter, for helping keep the magic alive.

7 responses so far

I hate orange urine

Jul 10 2009 Published by under Medical Musings, Medicine

On July 4th at 5 a.m., I'm loading the family into the car and driving very far away, where cellphones, pagers, and most critically the internet, do not work. Blogging has been very hard for me lately. I love writing, but due to work and family mishegos it's been hard to keep up with the posting. I'm hoping a stint up in the woods providing medical supervision to 400 souls will be rejuvenating. While I'm gone, I'll leave you with some of my favorite posts about the human side of medicine. I hope you enjoy reading them again, or for the first time. --PalMD
Urinary tract infections (UTIs) are a very common problem, especially in women. The link provided offers some very good information, but briefly, women's urethrae (the tube the urine comes out of), are closer to the rectum than those of men (who have a built-in "spacer"). This allows bacteria from the colon to creep over to the urinary tract and cause burning, pelvic pain, frequent urination, etc. I treat UTIs daily. Most are uncomplicated, but some are quite serious (usually in the elderly and chronically ill). As medical problems go, I love UTIs. When a healthy, young woman comes in with the usual symptoms, a quick test can confirm the diagnosis, and, usually, three days of inexpensive antibiotics fixes it. The patient is happy, I'm happy, everyone's happy. But then there's the orange stuff.
A few years back, a medication called "phenazopyridine" became more widely available as an over-the-counter drug. It is marketed to treat the symptoms of UTIs. It turns urine and other body fluids bright orange. This medication is useful for reducing the symptoms of UTIs, but does not cure them. The FDA does mandate certain labeling for the OTC preparations, but I can tell you from experience, the subtlety of this distinction is, well, subtle. Fortunately, you don't have to rely on my experience. Someone bothered to study the question. Most patients do not realize the difference between treating the symptoms and treating the disease. This leads to delay of treatment, and the infection can become more serious. To add insult to injury, phenazopyridine's orange pigment interferes with the most common tests we use to diagnose UTIs.
In discussions of medical ethics, the concepts of "paternalism" and "patient autonomy" are often thought of as being in opposition to each other. It is sometimes in the name of autonomy that medications are made more easily available to patients by skipping the physician prescribing process. (Also, over the counter meds are quite profitable). This can be very useful for medications such as ibuprofen, or Plan B (post-coital contraception), but any time you cut out the expert, certain risks accrue. Paternalism isn't the opposite of autonomy. The two work together. Patients see me for my expertise. They don't consult me about movies, art, or (thankfully) religion---just medicine. They do this because I'm the one with the training. Giving a patient knowledgeable advice is not paternalistic---it's what they came here for. I don't paternalistically command my patients to do anything. I dole out advice, and they are free to follow it or not.
Orange urine not only removes the expert, it fools the patient. It does not increase autonomy, it actually decreases it by deceiving the patient, perhaps causing them to become more ill.
<End of rant>

9 responses so far

They also serve who only stand and wait

Jul 07 2009 Published by under Medical Musings

On July 4th at 5 a.m., I'm loading the family into the car and driving very far away, where cellphones, pagers, and most critically the internet, do not work. Blogging has been very hard for me lately. I love writing, but due to work and family mishegos it's been hard to keep up with the posting. I'm hoping a stint up in the woods providing medical supervision to 400 souls will be rejuvenating. While I'm gone, I'll leave you with some of my favorite posts about the human side of medicine. I hope you enjoy reading them again, or for the first time. --PalMD
Mr. D. is one of those guys who is just nice. He's far from gregarious, but everyone who meets him likes him. He's quiet, reserved, and hates to complain. He's had his share of medical problems over the last 80 years---emphysema, stroke, cancer---all of which he's treated as inconveniences.
When he came into my office with his wife, he looked miserable. His back was hurting so badly that he couldn't get comfortable. It had been like that for two weeks, but he didn't want to bother me about it.
I asked him the usual questions---any fevers, weakness, incontinence---all negative. By history and exam, he appeared to have a usual case of low back pain, but with his medical history, you can never be too careful. He had been on immune-modifying drugs for an immunologic disease, so infection was a consideration, as was cancer. I did some plain X-rays in the office which were unremarkable, and he had an appointment with a spine surgeon in a few days, so I sent him home with some analgesics and instructions to call me if things got worse.
Things got worse.

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