Medicine still amazes me...and still lets me down

As I learn all the physiology, pathology and pharmacology that medical school has to offer, sometimes there are unique things I see during my medical training that really, really impress me.

Whether it's the capabilities of a 3D reconstruction of a CT scan of a bone or the heart, or watching a patient's debilitating tremor disappear instantly at the press of a button activating a microelectrode in their brain, or re-starting the still heart of a dead person inside the chest of someone else, I occasionally find myself with my jaw on the floor when I learn things that medical practitioners are able to do and see that, only a few years ago, were an impossibility.

Then again, judging by something that happened earlier this month, perhaps I'm just easily impressed.


The doctor I'm working with was called from his office to go see Catherine, a pregnant woman in the hospital. She is early in her third trimester, but started having contractions. Of course, he explained, calls like this come right at the end of the lunch shift to provide the maximum inconvenience to him and the patients waiting in his office. He also explained that disruptions to the office like this are a part of the reason many other family practitioners don't do obstetrics anymore.

We're taught that a lot of information from a patient can be gained from the first part of the physical exam - from "five feet away," or the first glance of the patient at the foot of the bed. This patient was a great example of this. We had barely entered her room, and right away, we knew that Cathy was not doing well.

More than anything, Cathy was incredibly anxious, and for good reason. On the drive over, the doctor had explained to me that Cathy had never been pregnant, and it had been her dream to have a child. She and her husband Dale had been trying for years. No reason for her and her husband's infertility could be found, and finally, after several tries of drug-assisted and then subsequently in-vitro fertilization attempts at a high financial and emotional expense, this woman was now pregnant. And at 41 years old, Cathy knew just as well as we did that if something went wrong with this pregnancy, there likely wouldn't be another chance.


The doctor did a quick exam, and was convinced that the cervix had not begun to dilate. The baby's heart was still beating normally, and monitoring of the uterine muscle contractions revealed uterine muscle activity, but it wasn't clear if this was due to actual contractions or more minor uterine irritability.

Just a few years ago, Cathy would likely be admitted for observation, at a cost of a couple thousand dollars a day. She might not end up being in labour, and might not end up delivering for weeks... meaning a long, expensive stay in the hospital, with an expensive air ambulance transfer to a big-city hospital, with little benefit. On the other hand, she could be sent home, then suddenly go into full-blown labour, and deliver a premature infant away from the hospital after being sent home. How do you spell "lawsuit" again?

I was surprised to hear that this dilemma is not faced nearly as often thanks to an expensive but convenient lab test looking for fetal fibronectin. This protein, made by the fetus, is found in the mother's cervical secretions only if the mother is likely to deliver within the next four weeks. By taking this swab, and getting the results from the lab a mere twenty minutes later, we were able to conclude with resonable certainty (the lab test is correct 15 out of 16 times, according to the packaging) that Cathy was not going to have a premature delivery, and that she could safely go home.


Despite the things I learn that amaze me, large or small, there still times that I am disappointed by the failures of modern medicine. So many diseases cannot be cured, and many can barely have symptomatic relief.

Earlier this week, I had to look into the eyes of a 83-year-old woman in a wheelchair who was begging me to fix her legs. She could no longer walk, and she desperately wanted to be able to. After she had left, my supervising doctor told me that she lost the use of her limbs because of a progressive neurodegenerative disease for which there is no cure, and she often forgets that this happened years ago because of her long-standing dementia. She has two diseases that, despite all of the advances in medicine these days, it still seems as though we can't do much more for her, and the millions with similar conditions, than apply a band-aid.


I'm told that throughout my medical career the advances in medical technology are expected to be staggering. Who knows what clinical decisions will be made much easier because of medical advances, or which devestating diseases will soon become relics of the past. Waiting to hear what the future will bring, and the chance to put these discoveries into action to change peoples' lives, is yet another exciting part of living a life of medicine.

Read the rest of this entry »

What doctors REALLY think... and preliminary thoughts on interdisciplinary health

"Research is a real problem. Doctors just make up the data. They don’t report negative side effects, no question about it."

Someone at New York magazine had a brilliant idea a few weeks ago.

"If I ask a bunch of doctors a bunch of questions," they pondered, "but promise them anonymity, just think all the great dirt I'll be able to print! They'll be so straightforward and honest, I'll be one of the few people on earth to know what doctors really think."

Someone at New York magazine seems to have forgotten about the medical blogosphere.

Every day, countless doctors rant anonymously about the dirt that goes on in hospitals. They just happen to do so in the form of blogging.

But someone at New York Magazine ended up doing the interview, writing the article, and hey, it got published. How Comrade found this article in the New York magazine online four full days ahead of print, I'll never know, but thank him, since you'll probably find it quite interesting.

Selected highights, my smartass comments in italics:

• Why you have to wait so long in a doctor's waiting room.
  It's because you are not the doctor's only patient.

• Doctors make up research data.
  Did you know that 86% of statistics you hear are made up on the spot?

• The way we train doctors now is worse than it used to be, because the residents who do surgery on patients are now allowed to do surgeries after they have had time to sleep.
  Yeah, you'll have trouble convincing me of that one. Say it with me: "Old-Boy's-Club."

• Patients have to wait for 45 minutes after they press the call button, not because nurses are standing around chatting, but because there's a nursing shortage.
  Hmm, so it's not just in Canada, eh?

• Doctors think that "By virtue of our training and knowledge, we can get away with... treating patients like shit."
  Strange, it took me only one year's worth of med school finals to get that feeling. At this point, I call it self-respect. Three more years of this and you'll probably call it me being an asshole.

• A doctor admitted to dropping a baby once.
  You think that's a big deal? Read the next one.

• Doctors feel powerful when they've killed somebody.
  I told you you need to read this article. Here's the link again.

After reading that article, I'm surprised that even at my early stage in the game, a lot of it I could have told you. A good chunk of it is, in fact, common sense. Think about it. Doctors like seeing patients that don't yell at them. Surprise. You have to wait in the waiting room for a long time because, well, doctors are seeing other patients. Surprise again.

But there's one thing that I'm surprised they didn't mention. It's...wait a minute, what? you want my opinion?

Sorry, but apparently in training for making a living by, well, mostly giving my professional opinion, it's been made abundantly clear that I am not to provide medical opinions of any sort. Not even to a friend who asks about their cold. Or growth. Or whatever.

Of course, I'll give you my opinion anyways. That's what this blog is all about. But here, I'm protected by my fancy disclaimer at the bottom of this page. Yeah, it probably provides little more protection than did those fancy flying-squirrel-like jumpsuits that early would-be aviators donned before jumping to their deaths, but at least it's something.

So here's what I think. I'm surprised the article didn't ask any of the doctors their take on the "interdisciplinary health team" that everybody is talking about.

I was talking about this interdisciplinary health thing with a nurse friend of mine the other day. I was going with that old joke that I find so funny (that no nurses see any humour in at all), telling her, "I can't wait until I've graduated med school so I can boss around nurses." (That is NOT how I will approach nurses on the wards...trust me, I know better.) But after we got back on speaking terms, we got into this talk about interdisciplinary health care - a concept that is very interesting, considering how little of it I've heard in my med school curriculum.

Medicine these days is supposed to involve all "health professionals" on an "equal playing field" - doctors, nurse practicioners, nurses, licenced professional nurses slash registered practical nurses (depending on your geographical location), respiratory therapists, physiotherapists, occupational therapists, chiropractors, naturopaths, quack cure-all syrup salesmen... (uh, in no, particular order...I swear...), all working together in perfect harmony like oompa-loompas churning out everlasting gobstoppers. If that's the case, though, and if it's the new wave, how come I haven't been taught that yet in medical school?

But that's another story for another day - I have a rant on that waiting in the wings...to be continued.

Click here to read the continuation of this post.

Read the rest of this entry »

Fumbling with the Tools of the Trade: Empathetic Statements

"... So I pulled out this empathy comment in front of a patient at my Family Practice class on Wednesday. I figured I hadn't used one in a while. I tried hard to mean it but I guess I didn't really, and so soon after I started saying it I began hoping the patient wouldn't catch me. It was slightly misplaced, and a little bit out of context. I felt really phony and I hated myself for it for a brief few seconds..."

---

I sometimes feel a little awkward using my new set of tools of the trade.

I'm not talking about the otoscope, or the opthalmascope, or the stethoscope, or the rectoscope (I can't wait!), or the tongue blade (apparently the technical term for 'tongue depressor'; the public caught on and started using the medical term 'tongue depressor,' so 'they' had to change the medical term to something more scientific and dangerous sounding. "Tongue blade should suffice," said the men in the white coats in the dimly-lit strategic medical equipment naming room.) Yeah, I'm all thumbs with all those tools still (as is my classmate who inflicted great pain on me whilst using one of the above scopes in a Clinical Skills learning session), but those aren't exactly the tools I'm referring to.

The 'tools' I'm referring to are the tools we learned during Communications Skills class, or "We Have A Past History Of Taking Crap for Our Graduates Being Socially Awkward And Insensitive To Patients So We Will Mandate That All Of Our Medical Students Take This Class On How To Talk To Patients Without a) Them Thinking The Doctor Hates Them, b) Them Thinking That They Will Sue The Doctor, Or Worse Still, c) That They Should Stop Donating Money To The Medical School From Which The Doctor Graduated." (That's the course title. Look it up.)

These 'Tools' are the Sit Down, the Get Consent or Die a Painful Immediate Death, and the most difficult to master secret ancient ninja maneuver, the Empathetic Statement.

The first two are pretty easy. "Sit down to create the impression of spending more time with the patient," we were told. Funny, I figured I'd just create that impression by spending more time with my patients. Shows how much I know. Moving on.

The second tool, Get Consent or Die a Painful Immediate Death, is pretty self explanatory and consists of making sure that the patient is willing to be interviewed by me. I have to get permission to talk to the people and I still don't even examine them on my own yet. Even if I screw this one up, my Medical School has covered their legal bases by layering - the patients are told when they book their appointment that medical students will be there, there is a "This Doctor is Teaching Medical Students" slash "Go Easy on the Medical Students, We Can't Have Them Quit On Us This Far In" certificate in the waiting room, the doctor asks them if it's OK to be questioned by a rookie, and finally I, the Medical Student of whom the patients have heard so much and are by now wondering why they have to be so sure they want to talk to me, ask them if it's OK.

(On a bit of a side note, in case there aren't enough side notes already, there are patients who decline to have their appointment on Wednesday afternoon once they find out that there are medical students in the office then. I'm collecting names so that I can decline to treat them or their children in the future. Just kidding, there are still some things that I don't mind putting off seeing in real patients until I've had a chance to be trained with standardized patients. You may recall what I'm referring to.)

Back to the tools. While the first two could be mastered by any layman, the final one, the Empathetic Statement, has pretty much become one of those things that haunts you even when you've punched your clock and have left work. It's awkward to wield, and takes a while to master, and at times you just close your eyes and hope it's working and you're not just embarrassing yourself, but when it is effective, man is it a deadly blow. It's kindof a secret weapon of new doctors, too, so don't tell anyone I told you this, we're sworn to confidentiality (which is why I'm sworn to anonymity)... I'll tell you, but I just don't want you, in your next doctor's appointment, to start wondering if a doctor is genuinely nice, or they have had to receive training on being nice to patients and are whipping out a full blown Empathetic Statement assault on you. Assume the former.

So I pulled out this empathy comment in front of a patient at my Family Practice class on Wednesday. I figured I hadn't used one in a while so I should get some more experience. I tried hard to mean it but I guess I didn't really, and so soon after I started saying it I began hoping the patient wouldn't catch me. I was interviewing this patient about her painful urination, now on my list of afflictions that I hope to treat rarely and acquire never, and I then chose to pull out an Empathetic Statement. It was slightly misplaced, and a little bit out of context. I felt really phony and I hated myself for it for a brief few seconds. If she wasn't so busy trying to make sense of my questions while I asked her to describe her pain in terms of its location, intensity, nature, character, mood, demeanor and favourite food and color, she might have noticed that my Empathetic Statement, "That must've been difficult," isn't exactly the most ideal interviewer response to "But the pain got better when I drank cranberry juice."

Okay, it wasn't actually that bad. I think what actually happened was that she told me that the pain was worse than ever before and I said that it must have been difficult. But I still felt phony saying it. This is what I'm talking about when I say that work stays with you even after you punch out. You see, it's rough when I do say something like "That must've been really frustrating!" spontaneously, even in normal conversations, because I feel like people - especially if the conversation is with someone in my class - they think I'm just pulling that out of my ass(ignment book for Communications Skills class). We joke around enough with FIFE (ie. Classmate approaches me and tells me they locked their keys in their car; I respond, "Awwww, how is this affecting your functioning? What are your fears?") so it's logical for them to think that I'm pulling out an Empathetic Statement because we were taught to, and not because I actually mean it.

Fortunately it doesn't usually go that bad. I have never actually gotten in trouble or accused of brash falsehood when I have used an empathetic statement, genuine or not. But I still hope this will stop being so awkward soon, and that when I actually do mean the statement, or even on those rare times that I don't and am just trying hard to be a bit more human, that my efforts will be appreciated nonetheless.

Read the rest of this entry »

The Impending Lawsuits, part 2

I've got a bit to add to my previous post entitled "The Impending Lawsuits."

I received a comment from one of my tutor group leaders in the journal I was writing for our class on the phycian's role in dealing with individual patients and soceity as a whole (yes, a journal... yes, a touchy-feely class... no, I haven't gotten anything out of it).

I wrote in that journal about getting sued, since apparently that has been on my mind lately, and he responded:

"Most doctors go through their entire career without getting sued once."

As well, in Canada, doctors are legally represented by the Canadian Medical Protective Association (CMPA) which provides legal services for physicians who are being sued.

A doctor whom I spoke with told me:

"the lawyers provided by the CMPA are outstanding. However, while this is good for physicians, sometimes it gets to a point where it puts patients at a disadvantage; I've seen patients who have had legitimate cases, but couldn't afford lawyers at the same calibre of the CMPA's, and therefore weren't able to successfully defend their case."

Read the rest of this entry »

The Impending Lawsuits

We've just started receiving lectures on the legality and ethics of medicine, and already we're all very aware that we are all going to get sued, inevitably, and soon.

One of my tutors, a family practitioner, told me that of all his friends in plastic surgery, each and every one of them has at least one pending lawsuit at all times. If one gets settled, there's always another one that is ongoing.

So every time I've heard of a doctor getting sued, I've started taking a mental note as to what they did, so that I won't do it. Here are a few of the mental notes I've collected.

• If a patient needs blood to save their life, and they're carrying a Jehovah's Witness card saying "no blood," don't give it to them.
  
• If you're putting in a central line and you put the needle in the wrong place, pull it out before adjusting the angle; moving it around inside will cause it to damage important nerve tissue.
  
• If you have gotten a patient to sign a consent form, it doesn't mean they've given consent. They can still pull their consent after they've signed the form, and the verbal dissent is what's legally binding.
  
• If someone tells you "Come help, someone is having seizures," don't reply, "Bring them here." If they're a reasonable distance away, failure to attend is professional misconduct.
  
• Don't diagnose things outside your office for your friends. Bad, bad, bad. If you do, don't forget to say, "If it gets worse, go see a doctor."

So you can understand why a post about lawsuits on a blog that I read and enjoy is one that I will undoubtedly read and remember.

EDIT (11/23) - Follow-up to this post here

Read the rest of this entry »