Thursday, November 15, 2012

(Re)learning How To Talk to People

 (as always any and all names have been altered/deleted to protect the privacy and anonymity of all parties involved)

By now the white coat has become kind of old hat.  I can’t believe I’m saying that because literally one year ago I regarded this addition to my wardrobe the crowning jewel—too often I now find it crumpled in a heap at the bottom of my bag .  Its interesting to me how quickly we readjust and more interestingly how quickly we regain the same level of dissatisfaction we were at before a “significant” life event.  

My whole life I feel like I’ve been counting down till med school and now I’m here and honestly I feel the same.  This is a matter of perspective and the dilemma of being unable to observe your life from the outside looking in really resonates here with me.  I can’t wait to be an attending but for now that seems like a lifetime away which was underscored by my realization of how incomplete my own clinical knowledge bank is and even further how immature my clinical judgment is.

I knocked on the patient’s door and  gently pushed the door open to enter the room with my best attempt at a friendly smile.  The patient was seated the armchair next to his bed in his washed out blue hospital gown and green socks with the grippy lines on the bottom.  He motioned me over and I took a seat perched on the edge of his hospital bed.
“Hi my name is _________ and I am at second year medical student at  ___________, and I was wondering if it would be okay if I ask you some questions about what brought you to the hospital?” I said with a little too much enthusiasm, even I caught myself off guard.
He responded “Sure, go ahead”
“Mr. _______? Is that correct?,” I continued
“And how would you prefer I address you?”
“Pete is fine”
“Okay Pete, thank you for allowing me to do this so lets get started”

For those of you who have been following me through this journey you will know how strongly I feel about asking that question (click here to see an old post regarding the same topic: Don't Call Me Bob).
From there I went through the CC (chief complaint) and HPI (history of present illness) and am finding OLDCARTS (onset, location, duration, character, aggravating factors, relieving factors, timing, severity) to be a very useful pneumonic in keeping the HPI in order.  It feels like something that will become more natural as my training progresses but for the time being I need a structure to follow so I don’t miss something.  A post of clarification of terms will be forthcoming.

We discussed the clinical course of Pete’s condition and his situation was not the most ideal for an M2 to be investigating because he had been admitted to the hospital due to some post-surgical complications, but we made it work.  I managed to wade my way through the remainder of the complete history punctuating that with a full ROS (review of systems) rapid fire in a way that probably made it impossible for me to glean any abnormalities even if they were present.  Quickly glancing through my notes I saw that I had collected all of the information I needed to do the complete write up that was required and turned to Pete and thanked him for his spending the time doing this with me.  Before I left I did something that I’m trying to make a habit of doing with all patients I see, I turned to him and said “Pete, if it wasn’t for patients like you none of us would ever learn anything or become better doctors.  Can you tell me what I can do, as a future physician, to make sure my patients know that I care? And can you tell me how I did?”

Although you have to use your judgment based on the patient’s conditions if they would be willing or able to engage in this discussion with you but I have found for the most part they are exceptionally receptive to this.  Shockingly to me I have learned the most about the patient’s medical conditions and personal lives in this follow up conversation.  This is after the “clinical encounter” is done.  It floors me to know that there is this huge untapped potential that is accessible to me that for some reason in my clinical persona suddenly become obfuscated. 

For now I foresee the largest challenge at this juncture of my training, and arguably indefinitely into my future, will be how to temper my personality effectively into my clinical persona.  Retaining a friendly demeanor and having interactions with patients that are based on trust and understanding while keeping site of the clinical goals, necessities and very real time constraints seems like a very difficult and delicate balance.  

Sunday, November 11, 2012

Teachable Moments II: Low incidence ≠ Low Importance

One of the most interesting aspects of second year is the team based learning components that are usually led by a physician who is a specialist on the particular topic we are studying (ie dermatopathology is taught by dermatologists).  These sessions are interactive and allow us to exercise some applications of the knowledge we have learned.  I really appreciate the higher percentage of MDs associated with our curriculum now versus first year that is very PhD heavy.  This isn't a criticism but rather an observation but is to be expected with a first year focus on basic science while second year starts to diffuse a serious clinical background into our learning.

While working through a patient case regarding some highly rare disease we all were disgruntled at the professor for having chosen something that was so unlikely.  One classmate raised his hand and voiced this concern: what's the point of talking about something that is so rare.  The professor's response to this is something that really resonated with me he said

"just because a disease is rare does not mean that it is rare for that patient"

It really hit me what those words meant and why we learn all of the minutia that we do.  Someone somewhere has this and if that someone happens to wander into my office I want to have the ability to help--to identify, to diagnose, to treat--with humanity.  Thats what got me, it was a reminder of the humility and humanity that is so quickly drowned out in a sea of lab values and patient findings.

When you step outside the house and its raining your first thought probably isn't welllll the chances of precipitation were only 25% so the fact that i'm 100% sure its currently raining is bothering me less.  To always be cognizant of each and every patient as a person, however cheesy and obvious that sound, is a principle I will strive to uphold in my career.

I have to admit that I never expected to be sitting in a classroom being lectured at and having that shape my clinical perspective, but it has.  Bringing physicians to us in a learning capacity provides us a tremendous asset in bridging the gap between book learning and clinical experiences.  That being said I think the most lasting and impactful lessons I am learning are when someone who has been a doctor for 30 years passes on a pearl like this one.  All day people teach at me how to read an EKG, how to differentiate between crackles and rales or how best to use an ophthalmoscope (left, left, left <-- more on that later) but what I want is someone to remind us how to do this while maintaining poise, grace and ultimately respect for the people who we serve.  I want more professors to remind us that becoming doctors doesn't gives us superhuman status, that it doesn't automatically grant us some kind of authority but instead we are being entrusted with an amazing responsibility.

for even more naive optimism and borderline preachy rhetoric see this old post