I've alluded to this before, already, that I'm against the constant rush of medicine from patient to patient. Today was another example. We had a patient who's been abused as a child resulting in traumatic brain injury on top of pre-existing cerebral palsy who's actually been doing quite well, married and working a regular job and ambulates around the house but uses a wheel chair outside her home. She came in for an acute exacerbation of her back and leg pain - pain which was previously well controlled by her pain management specialist - likely caused by some minor trauma worsened by her anxiety/frustration/stress. It was rather clear that the majority of her problem lay in coping with the new pain and the accompanying mental anguish. Her moods were rather labile as we later found out - during our interview she was extremely pleasant, sometimes tearful, but always polite. When we returned to check up on her she suddenly exploded in a fit of anger that rapidly became tears of frustration complaining that her pain was not being adequately treated. I felt truly sorry for her, and when the resident left to find a nurse she demanded that I stay by her side. I did feel a bond with her as I had interviewed her first, and could see that what she needed more than any medicine was simply someone to listen to her. She continued to cry and remained anguished despite my attempts to calm her down, and finally the resident called me over and I left her hurriedly. As we walked away from her, I thanked the resident for pulling me away but now I regret my action. I had clearly abandoned her in her moment of need. I used the excuse that my resident told me to follow her as an explanation for why I abandoned her, but that was a very weak excuse. She wanted to call her husband, probably someone who would listen to her and comfort her, but unfortunately my cell phone didn't have reception in the hallway. That was one of the major issues, I felt - her lyingi n the hallway. This is someone who's struggled against so many adversities that she cannot simply lie still. She wanted a TV, a book, anything to occupy her mind. I understood - I would be in similar straights if left to lie in a bed for hours on end without anything to do. We were waiting for a room to open up on the regular floor, and there she would get much more nursing attention than lying in the ER hallway where the nurses are outnumbered by the patients in a riduculous ratio.
So what did I do? Nothing. Absolutely nothing. I fled with the tail between my legs when the resident called, and then pretended that it was a relief to leave her. It was, truly, a relief in the same manner as not having to perform some courageous act simply by the command of another. Yet at the same time there was a feeling of shame, embarassment, if not inadequacy, in running away. I wanted to return to her and tell her good bye at the very least - not dissappear suddenly without any explanation. I feared that she would feel even more abandoned and become more aggressive/frustrated which serves only to alienate her nurses more and sets her up for a long, painful, and lonely night.
Yet I was a coward - I simply followed the resident back upstairs and tried to put her out of my mind. I hope she finally was able to speak with her husband, and hopefully got the pain medication that we asked the nurse to provide. It's so bad that I'm worried about seeing her again on Monday if she's not discharged. There's really no reason for her to stay, but if she ended up in the hospital on Monday, I'm not sure I can face her honestly after abandonning her like that.
Unfortunately, much of medicine stresses the efficiency and thus my talking with her, trying to comfort her, is actually frowned upon. I feel embarassed if I were to voice my opinion that I should return and see if I can somehow calm her down some more before leaving. I knew we had lots of other things to do, many more patients to see, but is that an excuse for ignoring a patient's concerns? Where do we draw the line between efficiency and sub-optimal care? Can we truly afford an one-on-one environment? This is where I think house visits (back in those days) had the advantage. Why can't we spend that same amount of time, dedication, per patient? With all the new technology, why can't we dedicate more face time with patients? Is it all in the name of capitalism that medicine strives for efficiency?!
Saturday, January 24, 2009
Thursday, January 22, 2009
Clinic
Today was my first foray into ambulatory neurology or "clinic". The day went by fast, and I re-learned quite a bit about the neurological exam. In testing for hearing loss, I got confused about the bone conduction versus air conduction. For some reason I remembered that bone conduction was more sensitive than air conduction, and thus performed the test backwards. No matter - it just means I have to review much of this material.
On the floors, we encountered another interesting case. This is an elderly gentleman who's had a long history of vasculopathies (diabetes, coronary artery disease including by-pass surgery, hypertension, etc.) and had a left cerebellar infarct about 6 months ago. At that time, they found an occluded left vertebral artery and a stenosed right vertebral artery. The plan was for him to get a stent placed into a vertebral or basilar artery but when he went for re-imaging to assess his vascular status, new acute and semi-acute right cerebellar infarcts were found. Listening to his story, they may have coincided with "falls" or questionable loss of consciousness. I was then tasked with reading up on bilateral cerebellar infarcts and after clinic that day I was able to peruse Medline and gather a few articles. Regardless of the etiology, it was rather clear by a decent sized study that his prognosis was not good - those with bilateral cerebellar infarcts in general tended to do worse, had more unpredictable hospital courses, and likely (but not proven) greater recurrences. Meanwhile, in terms of etiology, I believe it's quite likely that his severe atherosclerosis (manifested by his stenotic vessels and coronary artery disease and hypertension) made him vulnerable to atheroembolic strokes. As to why the cerebellar region, several papers seem to point at the lack of sufficient collateral perfusion when stenosis is present.
You can imagine my surprise, then, when cardiology came up and after an echocardiogram showing improvement in his ejection fraction (35%->45%) but questionable new lesions in a perfusion study was considering re-vascularization procedures! I asked the fellow if they were at all concerned about additional strokes given his severe atherosclerosis, and while she acknowledged that it was a risk, she felt it was not a great risk as the strokes did not appear to be embolic in nature but rather more consistent with hypoperfusion. I disagree with that notion, given that most hypoperfusion infarcts are not territorial, tend to be small (<2cm),>2cm) while his new infarcts from two different incidents were less than 2cm there were still localized to the posterior inferior cerebellar artery (PICA). Given his stenotic/occluded vertebral arteries, I fear he is in grave danger of new cerebellar infarcts. Since he was previously ambulatory around the house and didn't give any indications of cardiac deficiencies, e.g. shortness of breath after light exertion or chest pain indicative of ischemia, I'm not sure if re-vascularization is appropriate for him. If he were my grandfather, I think I would have resisted on the grounds that the risks are too high. Until he becomes truly symptomatic from a cardiac viewpoint, I don't see the need to do such an invasive procedure. His reason for admission was really from an incidental finding on MRI indicating acute cerebellar infarct, but he remains asymptomatic except for his "falling spells". Once we've ruled out syncope as the case of the falls, then I think it makes much more sense to "fall-proof" his home, perhaps physical therapy/walker, rather than continue to meddle with his body. I would hate to see him reduced from an ambulatory, semi-independent person into a comatose or severely disabled from additional cerebellar strokes. But as a student, I can do little but stand by and watch. Should I have been more vocal in my opinion with the fellow? She got her information from the notes left by Dr. Gerber the attending who has vastly more knoweldge and experience than I. Where exactly does the medical student stand as a patient advocate?
On the floors, we encountered another interesting case. This is an elderly gentleman who's had a long history of vasculopathies (diabetes, coronary artery disease including by-pass surgery, hypertension, etc.) and had a left cerebellar infarct about 6 months ago. At that time, they found an occluded left vertebral artery and a stenosed right vertebral artery. The plan was for him to get a stent placed into a vertebral or basilar artery but when he went for re-imaging to assess his vascular status, new acute and semi-acute right cerebellar infarcts were found. Listening to his story, they may have coincided with "falls" or questionable loss of consciousness. I was then tasked with reading up on bilateral cerebellar infarcts and after clinic that day I was able to peruse Medline and gather a few articles. Regardless of the etiology, it was rather clear by a decent sized study that his prognosis was not good - those with bilateral cerebellar infarcts in general tended to do worse, had more unpredictable hospital courses, and likely (but not proven) greater recurrences. Meanwhile, in terms of etiology, I believe it's quite likely that his severe atherosclerosis (manifested by his stenotic vessels and coronary artery disease and hypertension) made him vulnerable to atheroembolic strokes. As to why the cerebellar region, several papers seem to point at the lack of sufficient collateral perfusion when stenosis is present.
You can imagine my surprise, then, when cardiology came up and after an echocardiogram showing improvement in his ejection fraction (35%->45%) but questionable new lesions in a perfusion study was considering re-vascularization procedures! I asked the fellow if they were at all concerned about additional strokes given his severe atherosclerosis, and while she acknowledged that it was a risk, she felt it was not a great risk as the strokes did not appear to be embolic in nature but rather more consistent with hypoperfusion. I disagree with that notion, given that most hypoperfusion infarcts are not territorial, tend to be small (<2cm),>2cm) while his new infarcts from two different incidents were less than 2cm there were still localized to the posterior inferior cerebellar artery (PICA). Given his stenotic/occluded vertebral arteries, I fear he is in grave danger of new cerebellar infarcts. Since he was previously ambulatory around the house and didn't give any indications of cardiac deficiencies, e.g. shortness of breath after light exertion or chest pain indicative of ischemia, I'm not sure if re-vascularization is appropriate for him. If he were my grandfather, I think I would have resisted on the grounds that the risks are too high. Until he becomes truly symptomatic from a cardiac viewpoint, I don't see the need to do such an invasive procedure. His reason for admission was really from an incidental finding on MRI indicating acute cerebellar infarct, but he remains asymptomatic except for his "falling spells". Once we've ruled out syncope as the case of the falls, then I think it makes much more sense to "fall-proof" his home, perhaps physical therapy/walker, rather than continue to meddle with his body. I would hate to see him reduced from an ambulatory, semi-independent person into a comatose or severely disabled from additional cerebellar strokes. But as a student, I can do little but stand by and watch. Should I have been more vocal in my opinion with the fellow? She got her information from the notes left by Dr. Gerber the attending who has vastly more knoweldge and experience than I. Where exactly does the medical student stand as a patient advocate?
Wednesday, January 21, 2009
Rounds with Dr. Gerber
I'm rather excited about Neurology and am now wondering if I've made the wrong choice to pursue Internal Medicine! We had a grand total of 4 patients on our census, and with the 3 residents, 4 students, and one attending, we outnumber the patients 2:1! But that's not what excites me about neurology. For the very first time I was able to see evidence-based medicine at the bedside. We have 2 rather unusual cases, and after discussing them the attending, Dr. Gerber, went immediately to PubMed and searched to find case reports, reviews, articles, etc. that would substantiate his hypothesis or generate alternative explanations. But I'm also missing an important point here: Dr. Gerber, the attending, performed a full physical after a thorough, focused, history on every patient while we were rounding. Amazing! Never before have I seen an attending perform a full physical, often relying on the reported abnormal findings from the residents and focusing on the problem at hand. While there's nothing wrong with either approach, I feel that I learned much more from a complete exam than a focused one. The former has the advantage of being thorough, but the latter is much more efficient.
This makes me realize how important it is at various institutions to enforce a limit on the number of patients a person sees. While I understand that part of the training is how to handle a large number of patients effectively and efficiently, I also feel that this "rushed" medicine doesn't give patients the full attention they need and reinforces the message that it's ok to do just the minimum in order to get through all the patients. This might be ideal setup for future practice where your livelihood is dependent upon the number of patients you see, but I feel it's completely contradictory to the idea that we should be the patient's advocate.
This makes me realize how important it is at various institutions to enforce a limit on the number of patients a person sees. While I understand that part of the training is how to handle a large number of patients effectively and efficiently, I also feel that this "rushed" medicine doesn't give patients the full attention they need and reinforces the message that it's ok to do just the minimum in order to get through all the patients. This might be ideal setup for future practice where your livelihood is dependent upon the number of patients you see, but I feel it's completely contradictory to the idea that we should be the patient's advocate.
Tuesday, January 20, 2009
The transition
I didn't get to see any patients today - it was mostly lectures in the morning followed by case-based discussions. Once again I was reminded of how much I have forgotten, and yet also how much I still retained. Bits of pieces of random knowledge flit through my head as we go around the table asking and answering questions. All I recall from Neuroscience was falling asleep staring at the pictures of brain slices projected on the wall, and hallucinating about Mickey Mouse ears in the spinal columns. Yet, random items like the "reticular activating system", "corona radiata", jump into my head without bidding. Nevertheless, unable to make sense of much of the jumbled up bits of information, I'm dreading all the reviewing/reading I will need to catch up. I write, "Get textbook" as one of my "To do" items, along with a list of new terms I just encountered.
This transition is reminiscent of my return to medical school from graduate studies. For the past two and a half months I've been spending time in my old research lab trying to wrap up an old project and starting a new, exciting project. When I'm in the lab, I feel on top of the world - confident in my surroundings and familiar with the words, phrases, etc. of my field. When I'm in the hospital, I feel like a first year medical student all over again - timid, unsure, and uncomfortable in the basic tasks of getting a history/physical and formulating a differential. I find I much too often zoom on on a particular diagnosis and have a hard time pulling back and considering other options.
It's weird - in science I can often scrutinize the reports of other people's work as well as our own result and often bring up alternative explanations for the results. I do this to challenge the conclusions and when I'm out of objections I finally consider the results/conclusions valid. Why is it that in clinical practice I'm often unable to do this? Given a presentation, certain ideas jump into mind and I have a hard time thinking of others. Part of the problem, I believe, lies in my lack of confidence and lack of fund of knowledge, but partly also from the practice of medicine itself. I like coming up with a hypothesis and then testing that hypothesis with conclusive, diagnostic tests. However, oftentimes in medicine this is not possible. We can't always perform a biopsy to see what's going on. I feel that medicine is all about gambling - we all strive to beat the house by knowing the system, knowing the odds and betting on the odds, but rarely do we get a definitive answer. Empirical trials of drug therapy are all too common, and many of the "syndromes" and "diseases" are defined not by pathohistological/molecular/genetic standards, but rather descriptions. So many different causes can all yield similar outcomes, yet we all lump them together into a single syndrome. And then on the other hand, we have the genetic/phenotypic variability inherent in individuals that take a single causitive agent, e.g. infection with B. burgdorferis or Lyme disease, and generate multiple, different outcomes. What is medicine, then, if not simply guessing? We take a collection of symptoms and guess at the most probable cause (based on historical data) and then attempt to change the course (often with empirical trials).
Ever wondered how they got the "probability of precipitation" estimates in weather forecasting? That's right - it's a guess based on historical data compared to present day observations. Medicine is no different. We're simply glorified weather forecasters or car mechanics (more on that analogy perhaps in a later post), and that irks me.
It's odd that many physicians downplay the role of imaging - they pride themselves on being able to predict the outcome without resorting to expensive MRIs, CAT scans, etc. And yet the gold standard often remains "taking a look" - be it a surgical operation for a first hand look, a biopsy specimen for microscopic examination, or MRI/CT scans for imaging without having to open up the body. I see nothing wrong with looking at the inside of the body no matter how confident you might be in a certain diagnosis, because as I've alluded to before, it's most likely drawn on nothing more than probability, guesstimates. I believe that if we ever develop a truely non-invasive, fast, non-toxic internal imaging system, it would revolutionize medicine and change it from a "practice" to a "science". The alternative, of course, would be some sort of no-risk surgery. This idea, however, is what will ultimately doom healthcare with exorbitant costs - but more on that later.
This transition is reminiscent of my return to medical school from graduate studies. For the past two and a half months I've been spending time in my old research lab trying to wrap up an old project and starting a new, exciting project. When I'm in the lab, I feel on top of the world - confident in my surroundings and familiar with the words, phrases, etc. of my field. When I'm in the hospital, I feel like a first year medical student all over again - timid, unsure, and uncomfortable in the basic tasks of getting a history/physical and formulating a differential. I find I much too often zoom on on a particular diagnosis and have a hard time pulling back and considering other options.
It's weird - in science I can often scrutinize the reports of other people's work as well as our own result and often bring up alternative explanations for the results. I do this to challenge the conclusions and when I'm out of objections I finally consider the results/conclusions valid. Why is it that in clinical practice I'm often unable to do this? Given a presentation, certain ideas jump into mind and I have a hard time thinking of others. Part of the problem, I believe, lies in my lack of confidence and lack of fund of knowledge, but partly also from the practice of medicine itself. I like coming up with a hypothesis and then testing that hypothesis with conclusive, diagnostic tests. However, oftentimes in medicine this is not possible. We can't always perform a biopsy to see what's going on. I feel that medicine is all about gambling - we all strive to beat the house by knowing the system, knowing the odds and betting on the odds, but rarely do we get a definitive answer. Empirical trials of drug therapy are all too common, and many of the "syndromes" and "diseases" are defined not by pathohistological/molecular/genetic standards, but rather descriptions. So many different causes can all yield similar outcomes, yet we all lump them together into a single syndrome. And then on the other hand, we have the genetic/phenotypic variability inherent in individuals that take a single causitive agent, e.g. infection with B. burgdorferis or Lyme disease, and generate multiple, different outcomes. What is medicine, then, if not simply guessing? We take a collection of symptoms and guess at the most probable cause (based on historical data) and then attempt to change the course (often with empirical trials).
Ever wondered how they got the "probability of precipitation" estimates in weather forecasting? That's right - it's a guess based on historical data compared to present day observations. Medicine is no different. We're simply glorified weather forecasters or car mechanics (more on that analogy perhaps in a later post), and that irks me.
It's odd that many physicians downplay the role of imaging - they pride themselves on being able to predict the outcome without resorting to expensive MRIs, CAT scans, etc. And yet the gold standard often remains "taking a look" - be it a surgical operation for a first hand look, a biopsy specimen for microscopic examination, or MRI/CT scans for imaging without having to open up the body. I see nothing wrong with looking at the inside of the body no matter how confident you might be in a certain diagnosis, because as I've alluded to before, it's most likely drawn on nothing more than probability, guesstimates. I believe that if we ever develop a truely non-invasive, fast, non-toxic internal imaging system, it would revolutionize medicine and change it from a "practice" to a "science". The alternative, of course, would be some sort of no-risk surgery. This idea, however, is what will ultimately doom healthcare with exorbitant costs - but more on that later.
Monday, January 19, 2009
Medicine in Contemporary Society Requirement
Part of our school's graduation requirement is some kind of ethics/morals projects titled "Medicine in Contemporary Society". I chose the diary option as it's the most flexible from all the other choices (formal lectures, supervised projects, etc.). I often find myself holding opinions rather different from the mainstream, and I felt that writing a diary entry reflecting on my clinical experiences would be a great medium to express some of those opinions without having to argue for them (not that I don't believe in them sufficient to stand up for them, but sometimes it does get tiring to keep explaining myself). So, I'm going to go ahead and write them up in here and then print it out at the end.
Today we have off for Martin Luther King's day. Tommorow, I begin Neurology.
Today we have off for Martin Luther King's day. Tommorow, I begin Neurology.
Monday, December 29, 2008
Lack of personal responsibility
It seems to me that recently there has been a move towards avoiding personal responsibility - after all, if something goes wrong, so much the better to blame someone else rather than yourself, right? I was just listening to NPR's "Talk of the Nation" asking the question, "Who's to Blame When You Get Drunk?" and I'm disgusted to hear talk of making the bartender responsible (legally and morally) in cases where the person is obviously intoxicated. Wait a minute - was the bartender force feeding the alcohol to the patron? Who qualifications does the bartender possess to be able to make this determination of obvious intoxication? Is the bartender liable to further civil suits, e.g. if he refuses to serve someone of another race and is then accused of racial discrimination?! Further, where do we draw the line? I see hardly any difference between the scenario of a person who's clearly intoxicated purchasing more alcohol and being served and an obviously, morbidly obese person purchasing high calorie meals at a fast food restaurant. In both cases there are "clear visible" indicators (although again, I ask, what qualifications do the servers possess that will enable them to make this determination in an equitable and objective manner?), clear negative potential consequences (drunk driving, health-related issues including diabetes, etc.), and occassionally false/seductive advertising (strong proof than advertised/perceived, greater calories than advertised/percevied).
Ironically, I feel this attitude pervades even into the medical establishment. When something goes wrong, it's rarely a single person's fault, e.g. the attending. No, it's the system's fault - the nurses, pharmacists, doctors, and the whole infrastructure. Hence the whole emphasis on systems analysis. Whatever happened to ideas like commander-in-chief, captain of the ship, pilot-in-command?
In the air, there is always one person designated as "Pilot-in-command" (PIC), and no matter what else happens - even if air traffic control dictates one thing or other, the PIC is the sole person responsible for the safety of the flight. It's a serious responsibility, and one not taken lightly. I would venture to guess that a similar idea exists in the captain of a ship, and there is still some vestiage of that notion in drivers of vehicles - you don't see people complaining about system errors when they are involved in accidents/incidents - they are held accountable. Period.
Similarly, I feel the attending doctors should step up to the plate and take responsibility for everything - even the actions of the medical student. Ultimately, it's under his authority that the student is acting/learning. There should be an equivalent "Doctor-In-Command" principle and dictates no matter who says what, what rules exist or are absent, that doctor is ultimately the sole person responsible for the health and safety of the patient. Period.
So who's to blame when you get drunk? I think the keyword here is "...when you get drunk" Who decided to drink? You. Who decided to drink more than you should? You. Who decided to drive after driving? You. As others have pointed out in the comments for that NPR article, who decided to drive to a bar, intending to drink, and then walk out intending to drive home? You! Gee - who should we blame, then?
How about that argument that once you become intoxicated, you lose your ability to think clearly and make proper decisions. Gee - if a person became that intoxicated, and the bartender cut him off, where do you think he's going to go next? That's right - back into his 20,000 pound SUV and drive to another bar or go home. Do you think that a person who can no longer be trusted to make a judgement call as to whether or not he's had "too much" is perfectly fine to drive a vehicle? How does cutting him off from further drinks help this situation? Are you then going to have the bartender make sure that he's not driving? What if he walks back to his job (a surgeon, let's say) and kills someone? Who's responsible then?
Ironically, I feel this attitude pervades even into the medical establishment. When something goes wrong, it's rarely a single person's fault, e.g. the attending. No, it's the system's fault - the nurses, pharmacists, doctors, and the whole infrastructure. Hence the whole emphasis on systems analysis. Whatever happened to ideas like commander-in-chief, captain of the ship, pilot-in-command?
In the air, there is always one person designated as "Pilot-in-command" (PIC), and no matter what else happens - even if air traffic control dictates one thing or other, the PIC is the sole person responsible for the safety of the flight. It's a serious responsibility, and one not taken lightly. I would venture to guess that a similar idea exists in the captain of a ship, and there is still some vestiage of that notion in drivers of vehicles - you don't see people complaining about system errors when they are involved in accidents/incidents - they are held accountable. Period.
Similarly, I feel the attending doctors should step up to the plate and take responsibility for everything - even the actions of the medical student. Ultimately, it's under his authority that the student is acting/learning. There should be an equivalent "Doctor-In-Command" principle and dictates no matter who says what, what rules exist or are absent, that doctor is ultimately the sole person responsible for the health and safety of the patient. Period.
So who's to blame when you get drunk? I think the keyword here is "...when you get drunk" Who decided to drink? You. Who decided to drink more than you should? You. Who decided to drive after driving? You. As others have pointed out in the comments for that NPR article, who decided to drive to a bar, intending to drink, and then walk out intending to drive home? You! Gee - who should we blame, then?
How about that argument that once you become intoxicated, you lose your ability to think clearly and make proper decisions. Gee - if a person became that intoxicated, and the bartender cut him off, where do you think he's going to go next? That's right - back into his 20,000 pound SUV and drive to another bar or go home. Do you think that a person who can no longer be trusted to make a judgement call as to whether or not he's had "too much" is perfectly fine to drive a vehicle? How does cutting him off from further drinks help this situation? Are you then going to have the bartender make sure that he's not driving? What if he walks back to his job (a surgeon, let's say) and kills someone? Who's responsible then?
Tuesday, December 23, 2008
Keys
When I was a kid, I used to love keys - they represented to me power and responsibility, I guess - a symbol of adulthood. I still recall being especially proud of having a nice large key ring with many keys - bicycle locks, house keys, and even keys for such small things as diskette storage bins, etc. Now that I'm older than 30, I find myself appreciating smaller key rings. I've since shed most of the ancillary keys, keeping just the bicycle lock, house, and car key. I hope it's sign that I'm maturing...
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