Dear (in)patients...

Here's how you can make your inpatient stay more successful:

1) Carry a list of your home medications.  I want to hug you when you whip out a piece of paper, however scrappy, with the meds you take at home and their doses.  If you can't do that, at least bring all your pill bottles.

2) If you get most of your treatment at one hospital and have been admitted to that hospital several times in the past year, for the love of God, please go back to that hospital!  Please don't decide on a whim to come to this emergency room, because "I was at my aunt's house and it was the closest one." Your usual hospital is only 5 minutes away from this one!

Fact: your care WILL suffer since we have NONE of your past medical records.  And you know none of your history.  And while we try very, very hard to figure out what is ailing you, it is impossible to get the whole story at 2 AM.  We will waste a lot of time on our part and your part figuring out what you did and didn't have done at the other hospital.  And this will make our treatment of you here much slower and worse.  All the extra CT scans you get here because we can't look up your scans at the hospital...well, that extra radiation will give you cancer later on.

3) Be an active participant in your care.  We love it when you ask questions; we like it even more when your family is involved.  (Family involvement = positive prognostic sign)  To maximize your ability to participate, ask your nurse about the hospital workflow.  What time does the team round in the morning?  What time does the attending (chief) doctor round?  When does the team discuss your daily plan?  These are opportune times to ask questions. Even if we don't have time to answer right away, your questions let us know what's on your mind.  And then we can better prepared to come by later to discuss them.

Discussing sensitive topics

I volunteer at a primary care clinic a couple evenings a month. It's a wonderful opportunity to keep my clinical skills afloat and always work with really awesome attendings who are passionate about teaching and the mission of this clinic.

At my last clinic, we met a patient who urgently wanted to be tested for STIs, distraught over the prospect that he may have given his partner an STI. Between this immediate issue and his many other life stressors, the patient was having a very hard time coping. Given his emotional state, the attending asked to take the lead with the patient.  What I witnessed was a model of how to handle this kind of encounter. First, the physician heard the patient out. Rather than launching into a counseling session on STIs, what the patient really needed that evening was to vent. Then, she cited that millions of other patients have STIs and that when her patients who have a STI speak with their sexual partners, they do x, y, z. She completely normalized the situation and made the patient feel like 1) my doctor has seen other patients with this exact problem and 2) thereby, I am not alone with this issue - in fact x MILLION Americans deal with this! Finally, this physician encouraged the patient to page her if his situation ever overwhelmed him, effectively conveying, "I am always available to you and I will help."  The entire encounter lasted perhaps 10 minutes but the patient left feeling visibly relieved. These types of patient-doctor interactions remind me of why I went into medicine.

Family and Career

I love this post: the underwear drawer: continuity of care.

Thank you, Michelle Au, for advocating for and sharing your experiences as a physician and mother. I've been asked countless times (and have given much thought to) how I plan to balance the demands of family life and my career. I feel reassured when others are making it work.

Medical poetry

One of the prize winning poems Yale's medical student poetry competition.  I am so glad they are promoting the medical humanities.

Aphasia

By Noah Capurso

We are taught that the brain
Is a set of highways;
Corpus callosum,
Spinothalamic,
Optic radiation.

But there are other roads, as well.
Scenic neural backroads
That are hidden from view;
Dusty and seldom used.

Sometimes we can see them
When the highways are down;
From cancer,
Surgery,
Or a stroke.

Our patient had a brain tumor.
We tested her highways
With a feather drawing;
“What is this?” we asked her.

And the answer she gave
Came by the scenic route;
“A leaf
That fell
From a bird.”

Surviving medical training

Greg Bratton, a recently graduated family medicine resident, writes the blog "Insights on Residency" and shared his top 10 list of how to make it through medical training intact.

 I've copied his list below:

10. In college, major in something other than pre-med. You will learn enough science in medical school. Choose something like art, philosophy, or dance. It will expand your mind, and you will become well rounded and able to communicate with patients on a “natural” level.

9. Remember that, ultimately, you are a person first and a doctor second. Patients will relate to you. They will trust in your treatment plans and adhere to your recommendations. Find time to decompress. Take weekends off. Schedule date nights. Get involved with charities. Go fishing. Do something to keep in touch with who you are as a person. Don’t let medicine define you. You were John Doe before medical school, be John Doe after.
8. Date. Get married. Have children. Some say that it is too much to handle with studying, it is too expensive, or it is “just not the right time.” I disagree. I think it makes you better. Plus, no matter how hard of a day you’ve had or how grueling your week is, when you get home, someone is there to take your mind off of it. As a buddy of mine said after having his first son, “there are no more bad days.”
7. Read gossip magazines. After hours of memorizing Robbins Pathology or Grey’s Anatomy, you’ll need something to purge your brain. And what is better than keeping tabs on Lindsay Lohan, Britney Spears, and all the other train wrecks in Hollywood?!?! In addition, it will help you understand the many psychiatric problems you will one day be diagnosing and treating.
6. While at dinner, no matter how many of your classmates or fellow residents are present, DO NOT TALK ABOUT MEDICINE!! It always happens — you go out for a relaxing evening and inevitably start talking about work. Don’t do it! It is not fair to the non-medical professionals listening. Instead, talk about sports, weather, or the latest happenings in US! Magazine (another reason #7 is so important).
5. Periodically, wear normal clothes. I think we all will agree that one of the benefits to working in a hospital is the that you can wear scrubs every day. But remember, scrubs are forgiving; they won’t let you know that you’re not tying the drawstring as tight as you used to. Whether you weigh 150 lbs or 180 lbs, you are still going to wear the same size scrubs. Put on your jeans — they will tell you the truth about your circumference.
4. Exercise. Endorphins are good. Plus it will counteract the late night Cheetos, pizza, and soda consumed while being on-call or studying. And before you say it, there is always time! Just find it.
3. Call home. Talk to your mom and dad, brother and sister, hometown friends. Just because you’re “in medical school” does not mean you get to stop being their son, sibling, or friend. They are your support. Use them, lean on them, involve them. And remember, you are where you are because of them.
2. Keep an open mind while doing 3rd-year rotations. Even if you think you know what you want to do, don’t force yourself to like it. Enter each rotation with an open mind. Go with your gut. I wanted to do orthopedics but found myself “tolerating” the OR, not loving it. Yet, I loved taking care of families, seeing the same patient routinely, and developing relationships with patients. So I chose Family Medicine. Had you told me during my 1st or 2nd year of medical school that I would end up doing primary care, I would have laughed at you. But I love it and can’t imagine doing anything else.
1. Take a deep breath and relax occasionally. Don’t be like me and wait until you receive your diploma to re-center yourself. Do it daily. Know that although the journey is long, it doesn’t have to be rushed. Enjoy the moment. Enjoy the challenge. Realize that you, too, are on your way to achieving your dreams.

It's so very relevant and serves as a reminder that first, we are people, then doctors. Easier said than done, especially the part about making time for yourself and others. I think the only point I disagree with is that it's okay, no it's necessary, to talk about medicine with your friends! I did this throughout third year and it was a lifesaver. In fact, at our school, it's mandated - we had weekly hourly small-group sessions with our fellow third years led by faculty members who did not grade us. Each week we'd tell the group how we were doing and usually, at least one of us would bring up something we were struggling with or found really difficult. These sessions became a safe place to share how we were feeling and coping, to reflect, and to find validation through others' experiences. Medicine can be so alienating, and it helped being surrounded by others who you knew could understand what you really going through. One of the guys in my third year cohort commented just the other day that it was like "we walked through fire together" and really bonded as a consequence.

P.S. I'm wearing scrubs right now.  And I'm not even on clinical rotations any more. I think I just failed tip #5. :)

Doctor as Patient

An excellent post over at Kevin MD's blog about the lessons one doctor learned when he became a patient after suffering a nasty leg injury. The doctor makes several points about pain management that I think are especially important. So often we pooh pooh, discount, and inadequately control pain and this post begins to outline some of the complexities of pain management.

Heard in the hospital today

I'm getting the hell outta here!! 91 yo little old lady on stretcher to rehab.

Medication Noncompliance

We have a patient who had severe, New York Heart Classification III heart failure. He didn't take his medications. Not because he couldn't figure them out or couldn't afford them, but because he didn't think they would help. He was an educated guy, didn't think these Western medications would help. Instead, he went on a purification diet, felt better, and relapsed on his diet/alcohol and of course, went into florid decompensated heart failure. Over the course of his hospitalization, we tried to negotiate - his cardiology, our attending, our social worker, chaplain, family members, and now outpatient primary care doctors (2!) tried to explain the seriousness of his disease. We said hey, it's up to you, taking these medications; you're not to appease us but we've explained the risk/benefits and want you to make an informed choice. The guy has an EF < 20% for goodness sakes! He has a big clot in his left ventricle! We discharged him feeling better and he has been seen a few times by the primary care center. He is still noncompliant.

I have very mixed feelings about this but this patient makes me angry. Yes, that's right, angry. It is not an emotion that I often feel when I'm practicing medicine and I feel incredibly guilty about being angry at a patient. It is not in the ethos of medicine and sets up a terrible "us vs. you" mentality. I dislike patient conflict but also feel obligated to confront patients about their choices because 1) it affects their overall well-being and 2) it affects the well-being of the health care system. His prognosis is not good, especially without taking his cardiac meds like Lasix, an ACE inhibitor, spirinolactone, Coumadin, and will likely need an implanted cardiac defibrillator (ICD) in the future because of increased risk of sudden cardiac death. The next step after that is cardiac transplant. I mean, what's the ethics of giving people like this an ICD or transplant when they will not adhere to physician instructions? Yes, it is ultimately his choice, but we are paying for this every time he bounces back to the hospital in decompensated heart failure. I suppose this is a slippery slope argument but where's the line draw, say when in a few years, he becomes NY heart classification 4 and wants a donor heart?

Mobility in the hospital

The NYTimes's The New Old Age blog just posted a thoughtful piece about how the simple act of walking in the hospital (or "ambulating" in doctor-speak) can help maintain physical strength and ultimately long-term outcome.

From what I've observed in the hospital, the article is so accurate. So many times, I see elderly (and for that matter, young, previously healthy) folks walk into the hospital and then wither away during their stay. One of our attendings used to tell us that every week of bedrest meant at least a 10% decrease in muscle mass. It's a reminder that as a clinician, we can help prevent functional decline, or at least hasten recovery in the hospital, but encouraging patients and staff to "ambulate with assist."

It's like falling in love

From a email today from one of my college mentors, a physician and writer with heaps of wisdom and a sense of humor to match:
"Nothing is more fun [than clinical medicine] than falling in love."

Indeed, Dr. L, indeed.

Resources

I had a patient who was admitted for diarrhea - 3 weeks, every day 3-4 times/day. He came to the hospital because his daughter was worried that he looked gray and weak.  Turns out, he was really dehydrated.  So much so that his kidneys became temporally injured (acute on chronic kidney disease) and he was found to be hyperkalemic.  We took care of the hyperkalemia, but what about his diarrhea?  Ironically, his diarrhea disappeared while in hospital, just resolved entirely!  We did the whole workup - fecal cultures, leukocytes, fat, ova and parasites, stool osmolality, celiac disease workup.  It all came back negative.  This patient stayed in the hospital for 4 days.  4 days!  His hyperkalemia we corrected on the first day.  His diarrhea was resolved the minute he landed in the hospital.   In the U.S., we have such luxury.  If we'd been in another country, this guy would have been sent home after day 1, as he wasn't acute ill after his hyperkalemia was corrected.  There's nothing that would have been different had he gotten this diarrhea workup as an outpatient.

Another patient we saw was in her late 80s, who we discovered had a Cr over 7 (baseline in the 1s).  Acute kidney injury and we're starting dialysis on Monday.  Our attending mentioned that in any other country, i.e. Australia, that these individuals would not have the option of dialysis.  In Australia, apparently, individuals over age 65 are not eligible for dialysis.  Is our aggressive approach to care appropriate?  I can't help but think - this is what makes our health care so expensive!  Yet if I were these patients, I'd want the Mercedes Benz workup too!

Mr. G

Mr. G arrived on the Neuro ICU early Thursday morning.  A man who had barely crossed the threshold into middle age, he suffered from relapsed refractory leukemia.  The cancer had left him with few functioning blood cells, causing him to develop an intracranial hemorrhage.  The resident loaded him up with bag after bag of FFP and platelets, to no avail - his INR, at 1.7, would not budge.  Finally, she pulled the "big gun" and ordered Profile 9, a specialized blood product used as a last resort in coagulopathies.  The resident jokingly pointed out that with one click of a mouse, she had spent her entire year's salary on this patient.  (Profile 9 is apparently extraordinarily expensive.)  But the cancer had put its foot down, and his INR went up to 1.8.  The bleeding, however, was only one of his many problems.  Overnight, he had spiked fevers as high as 105 and no amount of antipyretics, chilling blankets, and even cold saline would touch his fever.

Mr. G's room was located directly across from the Neuro ICU resident "nook," where we sat to type notes,  examine images, and check lab results.  Even from 20 feet away, I could see that he was miserable.  Shivering and delirious, he managed to nod when we asked if he was nauseous.  His wife visited daily, and I learned that he had a young school-age daughter.  Over the next few days, I watched him slip further away and become less and less responsive.  Eventually, he was transferred to the oncology floor, where he died the next day.  In my short two weeks in the Neuro ICU, I would see 3 others on the floor pass away, but none that were as excruciating to witness as Mr. G.  I hope his family finds peace.

Neuro and the Stanford 25

It's been over a month since I've written and I feel that so much has happened since then. I see so many things in the hospital, and as I've written about in my last post, sometimes it is just easier not to think about them. Of course, the unconscious thinking doesn't, or rather, can't stop.

In any case, I'm currently on my neurology rotation, and it's been among my favorite so far. I finished two tough weeks in the Neuro ICU, spending long hours seeing very, very sick patients, most with such poor prognoses. I love neurology. I love how diagnostic it is, how doing a thorough neurologic exam correlates with the pathology. These neurologists are some of the best observers and diagnosticians that I've seen. I love how academic the field is, how we spend hours discussing patients and case reports and latest treatments based on clinical trials and pathology and pathways. At the same time, it intimidates me a bit. What I don't love is how little we have to offer these patients. Stroke - okay, let's watch it and make sure your BP doesn't dip too low. In the meantime, you're weak on your L side, encephalopathic, and probably just lost half of your ability to function.

At the beginning of third year, my top choice specialty was oncology. A field within internal medicine is still at the top of my list, and if I couldn't go into IM, I'd probably pick neuro. Neurology and oncology. Two extremely academic specialties. Two with very high morbidity and often, mortality. Tell me why I'm attracted to fields where the patients are sick, sick, sick and often die?

Other thing is that I really need to work on my physical exam. I can do the motions yet, but I certainly haven't any where near mastered the ability to elegantly palpate a spleen, access a thyroid, listen for heart murmurs. I like this site that I found from Stanford's Abraham Verghese, a physician-humanist who wrote The Tennis Partner. It's 25 "must know" physical exam techniques to master, called the Stanford 25. Yeah - go Stanford! It's here at: http://stanford25.wordpress.com

Physicians talking with one another: what a novel idea!

Yesterday, our weekly small group topic "Transitions in Health Care," referring to the process of transitioning pediatric patients with special needs/chronic illnesses from pediatricians to adult providers. The take home was that such transitions are hard and need to facilitated long before the child reaches "adult age" or age 18.

A couple examples of cases used in class: 20 yo Hispanic female with h/o Type 1 diabetes presenting to ED with out of control blood glucose after losing her health insurance at age 18 (why the heck does she have to be Hispanic??). 22 yo college student with h/o ALL treated at age 5 presenting to student health center for routine physical. Her pediatrician back home has been looking out for her before this. What issues need to be considered? How can we facilitate management of conditions that began in childhood in an adult setting?

One of my astute classmates asked at the end: "Why don't pediatricians and the new adult provider pick up the phone and have a 15 minute conversation about the patient?" Duh. Seems like a no-brainer. After all, in inpatient medicine, we have sign-out at the end of every shift, right? Yet, of course, the answer lies in financial incentives: because insurance companies don't reimburse for this, then these conversations just don't happen. Grr... another piece in this frustrating reality of how reimbursement strategies often limit effective healthcare delivery!