Teachable Moments III: Harm Reduction

I happily trotted through the front door of the clinic and planted myself in front of the elevator waiting to go up.  Although many students complained that their preceptors didn't know their names or didn't acknowledge them my experience was completely the opposite.

Dr. Parker was fantastic.  Not only was I clinically useless but mostly incompetent but he never made me feel that way.  He was kind, he was warm and he had this way of being reassuring that not only gave you confidence in him but in yourself, just for under his guidance.

A long time patient of Dr. Parker's, we'll call her Maria, came into the office for the 3rd time to finally be given a clinical diagnosis of hypertension.  Her BP was off the charts (in retrospect probably it wasn't that off the charts because if it was it would have been malignant hypertension--see me dropping that M2 knowledge--and we would have called and ambulance to take her to the hospital).  The obvious answer here was to start her on some pharmacotherapy and then make sure we could assure some compliance to keep her within a healthy range.

Much to my surprised Dr. Parker turned to her and asked what she thought.

Maria responded, "You know doctor, I really don't want to take a pill.  I know its really high.  I see that, but that is just not something that I want to do.  What are my options?"

"Well if we can get you a little bit more active and check in for another BP reading and see if its declined maybe we can hold off on taking a medication," said Dr. Parker.

For the next ten minutes Maria shared that some ladies at work had been walking a few times around the block at lunch time and doing yoga after work two days a week.  Dr. Parker and her decided she would try to get on this regimen with them and if the next time she came in it was still elevated she would choose to take the medication.

In my head I was screaming.  She had high blood pressure! She needed to take medicine to bring that down otherwise . . . and that was when I figured it out.  Otherwise what? She had been walking around  with this pressure for a while another week or two wasn't going to kill her, but giving her the opportunity to make a lifestyle change could alter the course of her life, could save her.

Too many of us, medical students I mean, are the type of people that see a problem, synthesize a solution and implement it in rapid succession.  Slowing that down, breaking the solution down into incremental chunks is a challenge for me.  I had the opportunity to witness a harm reduction principle in motion, before my very eyes.  For those of you who aren't familiar with the term it is essentially the idea that when you're wresting with a very severe outcome from an adverse event, any small decrease in the adverse event is a great.  Allowing free needle exchanges for IV drug users in order to reduce the transmission of HIV and Hepatitis C by infected needles is a direct correlate of this public health principle.

Dr. Parker met her where she was.  She wasn't ready to take a medication but she was ready to discuss adding some physical activity to her life.  If that didn't work or she wasn't happy with that outcome he would be there to guide her down another path.

At the time I left the clinic that day I was still baffled as to why the so obvious solution was not implemented immediately--but after some reflection I realized that making the conscious choice to delay use of that solution exemplified far higher level thinking.

(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

“Yes”

“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.  

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

Teachable Moments I

**please note: names have been changed for reasons of privacy**

Finally, no more shadowing and awkwardly stumbling around while my overly dressed up self scrambled to follow a doctor from room to room, nope because I’m a medical student.  It was time for me to get assigned to my preceptor for the year!  If you’re as confused as I was about what that is let me explain: physician shadowing, except this time you get to wear a white coat and a stethoscope.

 As first year students we come equipped with a severe lack of any clinical knowledge juxtaposed with a strong desire to act cool in clinic.

 A memory I know that I will reference for a long time in the future, as a yardstick for measuring how I have connected with a patient and family is from a day that I spent in the hospital with my preceptor rounding on patients on the Family Medicine service.  The day was essentially over and he decided to go check up on a few patients before heading out for the day.  One of the last patients we saw was an older African American man who was recovering from a brain surgery after a severe stroke.  The following is my recollection of that encounter:

“Hi, I’m Michael Parker, I’m one of the physicians taking care of your loved one today”.  Can we stop right there? Have you ever heard a doctor introduce themselves as not doctor? I feel like by the time we complete all of our training we wear our title of doctor not as a badge of honor but rather a triumph.  Maybe it was unintentional, maybe not, but in knocking on the door and simply stating his own name he put himself at the level of the patient and his family.  It made him immediately accessible.  There were two women and one man visiting the patient and he was wavering in and out of consciousness.  He was not able to interact at all, at that point the doctor would probably not have much to do, right?

Dr. Parker took the time to introduce who I was to the family and ask if it would be okay if I stepped into the room, they were more than happy to allow that.  He then inquired about how the patient was recovering from surgery and the family related that they were unsure how he was doing because of the unstability of his consciousness.  

Here it comes, teaching moment for life.  Dr. Parke proceeded to relate to me how difficult it can be for a family when they are going through a recovery process from such a major surgery especially when the course of recovery can be so varied.  He addressed me but also engaged the family in the conversation and they could be heard expressing hushed agreements—“mmhmmm” and “that’s right”—and nodding along as Dr. Parker conversed with me.  He then turned back to the family who had been listening to him with rapt attention and asked them again if they had any other questions.  The woman sitting at the patient’s bedside echoed some of the sentiments that Dr. Parker had shared with me while the other family members nodded in agreement.

It was amazing for me to see how in such a creative way he was able to express the uncertainty of the situation for their loved one without robbing them of hope or giving a promise of too much.  By the time we were ready to leave the room the patient’s visitors were wishing me the best of luck in my career and relating that they had a niece who had similar aspirations.  Before we left Dr. Parker thanked the family for allowing us to speak with them and noted that someone would check in with them again shortly. 

The lesson I’ve learned from Dr. Parker is that we will have an urgent responsibility as physicians not only to treat patients but also to effectively interact with the environment around them. In that conversation there was nothing Dr. Parker did directly for the patient, but he reinforced the support system that will be vital to this patient’s recovery, something that is integral albeit indirectly to the patients health.  In that moment he transcended race, gender, age, ethnicity and socioeconomic status.

It is of great surprise to me to know that no matter how much we prepare and study it will only be with time and an active desire to improve that we will come close to delivering optimal care to our patients, I think I now have a greater understanding of why we practice medicine. 

Doctors: Humanitarians First, People Later

Warning: I may get a little preachy here, the line between opinion and fact will be blurred, but please try to look past that and understand what I'm trying to get at

Whether you are currently a medical student or even a doctor or just beginning to contemplate the idea of pursuing a career in medicine you have at some point pondered what has pulled you that way. Stock answer "i want to help people".  We're so programmed to think that and to say that but I feel as though the true force behind that statement has been diluted.

What prompted me to write this post was the onslaught of status updates via different social media regarding the absolutely horrific events that unfolded at the Batman movie premiere.  There were a variety of different reactions as well as differing levels of sensitivity (or insensitivity) that got me to thinking.  I realized then that insensitivity (be it online or otherwise) strikes a chord with me the most when the individual is a medical student (and as the slow progression up the totem pole of medical education occurs for me eventually it will be residents, fellow doctors, etc).  No matter how human we may be by taking on the role of physician we are answering a higher calling.  People expect more.  There is an expectation that you are more caring, more understanding, more sensitive and more skilled in empathy than the average person.  Additionally, we are all in this thing together, if one med student is a jerk I feel like it reflects on use poorly as a community.

Maybe there isn't an expectation and I came into this with my head in the clouds but I do feel that way. We owe it to ourselves as well as our future patients to shift our world views in a way that allows us to empathize first, judge and mock later

One of the hardest lessons the past year has taught me is that although I chose medicine because I absolutely am enthralled by the inner working of the human body and because talking to people, learning their stories and understanding how I can bridge the gap between science and medicine and society and culture, not everyone does.  Sometimes people want to go to medical school because they have a passion to serve the underserved while others crave the honor and prestige of being a world renown surgeon while others still simply want to secure themselves a certain type of lifestyle.  The toughest pill for me to swallow is that its okay.

Medical school gives you ample opportunity to self reflect from a pit of angst and rage, it is easy to forget the optimism and lofty ideals that may have brought you where you are, but I implore each and every one of you to look deep down inside you and hang on to that thinnest thread of wanting to care for people.

I am a firm believer that little things like that can truly change the face of medicine.

Don't Call Me Bob

First history taking workshop ever.

I smoothed the creases from my clothes, made sure the hem of my pants wasn't tucked into my socks and straightened my shirt out.  Carefully taking it off the hanger and sliding it on, the pièce de résistance, my white coat.  I stood there feeling a little bit in awe of myself.  I had waited so long, it felt like my entire life for this moment to finally put on that coat in a serious capacity.  

It was the first clinical skills workshop of the year.  This was the first time I would put to use the tedious amount of instruction we had received in clinical skills plenary sessions about how to interact with a patient, what to ask, how to ask it, when to ask, how to diagnose, how to rule out one disease versus another.  I was pumped.  It was gonna be my first day of doctoring.

What I encountered could not have been further from what I had imagined.  We were all herded into a room where we proceeded to split into groups and each group was to interview two mock patients.  So here we are sitting in a large multi-purpose room in the college sitting around a "mock" patient (these were people who did suffer from the medical conditions they were describing to us but had been nice enough to subject themselves to the utter clueless-ness of M1s) who we were supposed to interview as if in a clinic setting.  There were six of us so we went around the circle (like it was a second grade sharing time) and each asked questions until we had exhausted our totally inadequate list of what information we needed to elicit from the patient. 

I went home from that experience feeling so much less like a doctor than I wanted, essentially nothing like a doctor.  That was when I realized how many eons away I was, we all were, from even being comfortable enough with ourselves in a conversation with a patient to be of any use clinically. 

One thing that struck me from that day, that I will never forget is something one of our patients shared with us.  He was an older gentleman who shared with us that for years and years he had harbored some slight resentment for his primary care physician because the young chipper doc had affectionately called him "Bob" from the very first visit.  The doctor didn't realize what a colossal misstep it had been not to ask the patient what he preferred to be called, although the patient had approached the situation with a 'grin and bear it' attitude and eventually came to like the physician there always remained that initial feeling of discontent.

It seems like such a small thing, just tell him not to call you Bob, but it isn't.  As physicians we often are in situations where the power is shifted tremendously on our side and away from the patient.  For that reason I believe it is of utmost importance to cultivate a relationship that gives the patient a loud enough voice even if the only thing they want to say is "Please, call me Robert"