Tuesday, August 31, 2010

The Good, the Bad, and the Ugly

Listening to patients for the past two weeks, we learned quite a bit about what patients appreciated about their doctors and what had left them hurt and confused.

The good:

M., an elderly lady with a very close relationship with her primary care physician, said she had been to many bad doctors in her life.  She knew right away that her current doctor was different, that she "could just tell."  M. didn't feel like she was wasting the doctor's time.  What was so special about her?  "She listened.  She really listened."  When asked to elaborate, M. had a difficult time describing the intangibles that struck her.  The two just clicked.  "It's a gut feeling."

From a doctor, three A's: "ability, affability, availability."

I interviewed a cardiac patient and his family in the hospital who were very grateful for the team of doctors that cared for him.  The family mentioned a doctor at a different institution, who, after a long day, took them aside for a private conversation.  He asked how they were doing and if they were taking care of themselves.  "Are you sleeping?  Are you eating?" he had asked.  "You need to take care of yourselves so you can take care of [the patient]."  He spoke to the family for 45 minutes, until nearly 10 pm.  "During that time, his wife called him several times," recalled a family member.  "He just said he'd be home soon."

The bad:

That same family recounted a time when their father/husband was undergoing a fairly long surgery.  After waiting for any sort of news, the family finally heard from a few staff members that the surgery turned out fine (no more detail than that). A bit later, they noticed the surgeon step out and they approached him and asked him for additional information.  "Did you talk to my staff?" he asked.  They said they had.  "Then you know it was fine," he answered brusquely and turned and walked off.  "It was as though he considered any of his time talking to us a waste."

The ugly:

A classmate of mine mentioned that when she had interviewed a patient, the patient had mentioned that she had surgery which had left a scar on her chest.  Her doctor had told her that it shouldn't be a problem, since she was never going to wear a bikini anyway.

Saturday, August 28, 2010

Letter to a Young Doctor

Thursday was our final day of Introduction to the Profession, a course which had us shadow doctors, interview patients, "save" simulated patients, discuss professionalism and cultural competence, and work through clinical cases and meet the real patients afterward.

During the last hour, we were asked to write a letter to our 2014 selves reflecting on what characteristics and attitudes we want to retain, as second-week students, over the next four years.

Dear Me,

I hope you're healthy.  I hope you're well.  I can barely imagine the changes you will undergo, the people who will change your life, the experiences that will leave their indelible imprint.  As I think of what the next 48 months will bring, questions flood my mind.  Do you still cry at the drop of a hat?  Did you keep your sense of poetry?  Of imagination?  Of empathy?  Does the idea of taking care of a human being still terrify you?  Are your arteries clogged with four years' worth of frozen dinners?  (Please learn to cook!  And find time to zumba!)  But most of all, are you happy with the path you've chosen and with what lies ahead?

Today I sit and think I know myself well.  I am a layperson's layperson.  I call heart attacks "heart attacks" and not "myocardial infarctions."  I have been outside the white coat more than I have been in it, and I still associate with patients.  I sometimes mistrust doctors, I don't consider medicine a monolithic profession, and "medical culture" is still foreign to me.  I worry that as my classmates and I grow closer through emotionally and mentally demanding experiences, we will become acculturated--part of a profession that has its rewards and excitements, no doubt--but part of a culture that also encourages a divide between provider and patient, healer and healed.  I fear that I will succumb to the mantra, "They don't know what we go through, what we see.  They don't really understand.  They don't get it."  I hope I don't see the world as a "they."

I recognize my personality quirks, and I welcome changes in behavior, especially with patients.  I am shy and unsure, and I hope I can grow into the role of physician.  I don't expect to eliminate unsureness, but I do hope to act within the bounds set by it.  I hope growth comes as I learn more about my likes and dislikes, strengths and weaknesses, and frankly as I learn what is realistic and what is not.  Will I still want to be a hematologist/oncologist or a neurologist/psychiatrist once I work in the fields?  What and who will lead me to make my specialty choice--and what will I research, and who will I teach?

I hope I am knowledgeable, and I hope I am responsible.  I hope I still sometimes look in the mirror, see my white coat and scrubs, and wonder what I did to earn this incredible privilege.  I hope I am still humble, and I hope I am still awestruck.  I hope to never have an ego the size of Jupiter.  I hope to keep reflecting, and I hope to keep writing.  I hope I have dilemmas, because if I don't, I am colorblind.  I hope to sometimes be mystified, but not to be paralyzed by indecision.  I hope always to keep options for my patients, and to never dismiss one or reach a dead end.  I hope I maintain close ties to my old life, and I hope I have the patience to explain to my family and friends what I experience.  I hope I act nicely, and I hope I am not faking.

I want to keep the passion and the drive to become the best physician, the best researcher, the best writer, the best teacher, and the best person I can be.  I hope I find love, in whatever form it may take.  And... I just hope.

I wish you all the best, and I'll see you in four years,
Shara, '10

Thursday, August 26, 2010

My Little Shadow

For first years, shadowing is a basic part of our clinical experience. I recently had the pleasure of shadowing an oncologist one-on-one in an inpatient setting. He was fairly high up on the totem pole, and after two hours and five patients, I could see why.
From my observations:
  • The oncologist rarely used numbers. A treatment didn't have x percent chance of success, and a patient didn't have x weeks or x years. His words qualified, not quantified.
  • He was frank with patients. Seeing a white coating inside a patient's mouth, he suspected the horse (thrush, a side effect of treatment) but did not hesitate to mention the zebra (oral cancer). Again, instead of tossing around numbers, he simply said, "It's probably okay, but I still have to check."
  • He was franker with me regarding his expectations and frustrations. He mentioned that "I can get most patients to do what I want them to do, as long as I phrase it the right way or draw them the right pictures." But he expressed exasperation with intransient paients. Regarding a lady who, for inexplicable reasons, was willing to undergo an invasive bone marrow transplant but not a routine vaccination: "I'm working hard to save her life from cancer and she's going to **** it up and die because of something like that?" Another man's leukemia spread dramatically. With the patient, he was all business, making plans for treatment and not giving an explicit prognosis. When I asked more specifically about the prognosis, he predicted that he would probably die within the year.
  • He strongly believed that a physician, with vastly more knowledge and experience than a patient, should not remain neutral on treatment options. "Never say to a patient, 'Here are your two options. You decide what you want to do.' Tell them what you would recommend and why."
  • He never assigned blame. When I asked if a patient's cancer had spread because of his refusal to get treatment initially, he told me that it was dangerous to think that way and it's almost impossible to pin down murky causes like that.
  • He said "I don't know" once but had a clear plan. Even if that plan was just waiting and watching.
  • He was meticulous about details and trends. He continuously analyzed minor changes in blood cell count and cancer cell count (and informed the patients about these), and he did not jump to potentially unnecessary treatment without waiting a few weeks to gain a better handle on the bigger picture.
  • He was a brilliant and compassionate physician, and it was an honor to shadow him.

My Big Bird

"Which medical show on TV is the most realistic?" the oncologist I was shadowing today asked me.

No way could it be House, Grey's Anatomy, or Scrubs.  Boston Med?  (The show was filmed at one of the hospitals I was shadowing at--was he tooting the institution's horn?)

Surprisingly, Scrubs--with all its quirks and absurdities--was his answer.  "It deals with the insecurities and doubts that we all face," he said.  The character traits are dead on.  "Plus, it's hilarious."

His favorite episode involved a patient who died because of a medical error.  The show closes with a powerful scene: to remember their mistakes, the four main characters walk around the hospital with his ghost following each of them.  Apparently, oncologists feel the same way about some of their patients (regardless of whether they blame themselves).  They don't easily forget.

In fact, later that day, the oncologist was going to a patient's wake.  He said it wasn't a common thing he did--but it wasn't rare either.

Wednesday, August 18, 2010

Jim the Sim

Today we confirmed that we are indeed alive.  In small groups, we practiced finding each other's pulses, taking blood pressure, and listening to lungs.  None of us had pneumonia (crackling sounds in the lungs), no one was dehydrated (drastically different sitting and standing blood pressures), and no one was having an asthma attack (whistling).

Taking the respiratory rate requires more social grace.  The only way to determine how many breaths a person takes per minute is to watch them breathe in and out for 15 seconds or so.  Staring at a patient for that long is probably a bit Hannibal Lecter-esque, so this is the time to make small talk about their hometown or the weather and count their breaths.

After taking vitals, we were introduced to a "model patient."  Six of us gathered around the simulator, voiced by our instructor in the next room.  "I'm Jim, and I was just practicing for a triathlon and then suddenly I couldn't breathe very well."

We look at each other helplessly and start asking questions.  Has this happened before?  Are you in pain?  Are you currently taking any medications?  Do you have any other illnesses?  Do you drink or do drugs?  His blood oxygen levels are getting dangerously low, so we quickly give him an oxygen mask.

Jim apparently had asthma and an inhaler, but "I lost it a long time ago."  Okay.

Then, "You guys are doctors, right?  Aren't docs always using stethoscopes?"  Hint, hint.

It takes the six of us a bunch of minutes to confirm crackling in his lungs.  Is it asthma?  An obstruction?  Pneumonia?  Let's get a chest x-ray.  "What's going on?" Jim asks.  "Is it that radiation safe?  I want to have kids."  It's hard to talk and think; throughout the exercise, we periodically forget to clue Jim in on all the procedures we're about to do on him or how he feels afterward.  (Another group was seconds away from sticking a chest tube into their conscious patient when one of them asked, "Oh, should we tell her what we're doing?")

The results pop up on a screen, and of course we have no clue how to interpret them.  Time to get the radiologist on the phone (also voiced by our instructor).

 "What's your patient's name?" he asks.  "Jim..."  Hmm, maybe we should've gotten a last name.

Jim's lungs are hyperinflated, a sign of an asthma attack.  Soon we are giving Jim an albuterol inhaler and he is breathing better.

His heart rate is still slightly elevated, though.  Is it just anxiety or something more?  Today, we have unlimited resources, so we ask for an EKG (the exercise is not a simulator for real world cost-effectiveness, apparently).  We get a cardiologist on the phone.  Why did you order this?  "His pulse is a little fast," we reply, feeling a little bit like the medical students who cried wolf.  "It's okay, I need to send my kids to college," he answers.  The EKG is predictably normal.

Should we use beta blockers to depress the heart rate, or is the heart rate just a consequence that will resolve since we've resolved the initial problem?  In our limitless world, we order beta blockers.

The pharmacist calls us up.  Tell me about your patient, he says.  After we do, he says, "Just to let you know, beta blockers are contraindicated in patients with asthma.  Do you still want to give them to him?"  Hint.  Um.... nah.

After a few more tangents, Jim's primary care doctor calls and tells us that elevated heart rate is a side effect of the albuterol.  Oh.  Where do we want to send him now?

What's on the menu? we ask the nurse (our other instructor).

"The OR?" No.
"Intensive care?"  No.
"The floor?"  Maybe.
"An observation unit?"  We can watch him there for 24 hours.  Sure.

And so, half an hour and a lot of tangents later (followed by a debriefing by our instructors), Jim has been successfully treated for an asthma attack by the greenest of the green: third-day medical students.