Medical Musings
palmd | February 8, 2009In 1999, during my intern year, Hurricane Mitch struck Central America. As stated below, I wanted to become involved. The program director of my residency was kind enough to view this as a worthwhile educational experience. This is my diary from the trip.
Beginning
The idea to go to Honduras came about in a way that may or may not be unusual. I have no way to judge, never having done it before. I had of course heard of the disaster of Hurricane Mitch. As I listened every day on the radio, I thought about all of the potential deaths that could be avoided by simple medical care. One day on NPR…
palmd | February 5, 2009Returning phone calls isn't my strong suit. I'm not sure what it is, but I'd rather just take the calls as they come, whenever possible. I usually let my patients know to have me paged if they need anything important, so it's not unusual for me to hear from my patients at odd times. It's a bit more unusual for me to have patients show up at the office without an appointment. I always squeeze people in if they call, but it's a little harder if they just walk in (and the staff hates it---I guess it throws them off their game). So when Mr. Y showed up one morning, it was a bit of a surprise…
palmd | January 24, 2009I don't have a lot of experience with small hospitals. My medical school's hospital was about two square blocks of buildings, all of them attached, ranging in age from 100 years to 10 years. The were connected by irregular bridges and linked (ex)-fire escapes, and by miles of dim tunnels.
During my residency, the campus covered several square blocks, with buildings linked by more airy bridges (a la Minneapolis) and "secret" tunnels that you could find if you just knew where to look---although getting lost underground was the rule.
My current hospital is---by number of admissions---one of…
palmd | January 15, 2009As I sit in my (very narrow) seat on a DC-9 heading for North Carolina, one thing in particular strikes me: I'm really, really pleased that there is no such thing as "alternative engineering". It's not that "allopathic" or "mainstream" engineers never make mistakes---bridges collapse, cars break, computers die---but most of the time, our buildings, tools, and machines work. In fact, they work so well that we rarely think about all the work that has gone into creating them. Still, even when our houses fall down or our toys break, we don't go running for a "new kind" of engineering. We…
sb admin | December 26, 2008My father-in-law wore his nickname without irony. His was the kind of nickname that would be tough to bear on the playground, but despite being a teacher for decades, any juvenile thoughts wouldn't have crossed his mind. I don't think he knew how to be insulted.
And while he may not have been easy to insult, he did have pride, and as he became more and more disabled by chronic illness, his frustration grew. His attitude and that of his wife was remarkable. Sure, he complained about being dependent on others, but when he needed to start dialysis, he took it in stride. When he became…
sb admin | September 17, 2008I love language, which I suppose is as good a reason as any for being a writer. I'm also terribly critical---I hate misuse of language, especially my own. I'm not talking about silly grammatical rules that real speech renders moot. I'm talking about the misuse of words that actually changes meaning.
Every day I give bad news. I hate it. For me, it's an everyday thing---not routine, exactly, and not rote, but profoundly normal. For patients, it's the furthest thing from normal. Bad news doesn't come every day. No matter how everyday it is to me, my words can deliver the worst news…
sb admin | September 9, 2008(I felt Doctor Signout deserved a more complete answer, so here it is.)
I'm surrounded by cynicism. Doctors make particularly good cynics (although not always the best skeptics). Why are we cynics? Pehaps because we see human behavior in the raw. On a daily---no, hourly---basis, we see people making decisions that destory their bodies. People who make good decisions end up at the doctor, but people who make bad decisions seem to end up at the a lot doctor more. Much of the pathology I see is preventable disease.
Still, doctors' cynicism is often tempered by a good deal of compassion. I…
sb admin | August 22, 2008I'm a little down today. I've told you before that I take care of my own patients in hospice. I've also told you about watching patients and friends lose their battles with disease.
This week I had serious talks with several people about end-of-life issues (the details of which I can't really share at the moment). I've also had to tell someone about an abnormal lab result (a very bad one). In fact, the best news I've delivered all week was telling someone they had mononucleosis (rather than something worse).
I've found, in my limited experience, that terrible illnesses don't change…
sb admin | June 17, 2008I love fountain pens, but I'm far to busy for the regular ritual of cleaning, filling, etc. Most of my day is spent scrawling notes or typing on a keyboard. But there is one task for which only a fountain pen will do.
I've lost a number of patients lately. Most were in hospice, all were elderly, but it's always tough. I take care of my patients until they die, including hospice care, so I often get to follow them on the journey from health to death. Sometimes, great debility and dementia is a step on that journey. I've taken to writing short notes to the spouse of the deceased, to…
sb admin | June 5, 2008When a resident of student presents a patient with me and I help them formulate a plan, we call it "staffing" the case. Recently while I was staffing, I was presented with a patient who speaks little English, but speaks another language fluently. Unfortunately for us, this language wasn't Urdu, Spanish, French, Romanian, or Hindi (languages spoken by the people immediately within my reach). The medical instructions we needed to give were fairly complex---too complex for Pidgin English, so I paged one of my interns.
"Hey, S.," I said, "how well do you speak (insert little-known language…
sb admin | June 4, 2008I am often the bearer of bad news. I don't think I've ever been formally taught how to deliver bad news, but I've developed a style over the years, and I'm pretty good at it.
I work with medical residents every day in their outpatient clinics. Most of them have never had to deliver bad news. Some people are natural communicators, and some aren't. Often, one of my residents just "gets it"---they have a great deal of empathy, can "read" the patient from moment to moment, and without any help from me, they can successfully give the news.
What does it mean to give bad news "successfully"?…
sb admin | June 3, 2008In the interest of blog synergy, I'm reposting this from my old blog.
I'm actually quite lucky. Despite being surrounded by infectious diseases for sixty hours a week, I don't get sick all that much (OK, maybe more than most, but I don't have data). I actually called in sick for part of the day, something I rarely do. And that got me thinking...
When I see a patient with the flu, strep throat, and other infectious diseases, I recommend that they take several days off from work---not just to recover, but to avoid sharing the bugs. A high percentage of my patients refuse, due to fears of…
sb admin | May 23, 2008Here's the conundrum:
Let's say your patient's insurance has decided that they will pay for 12 sessions of reiki for, say, back pain. All that the patient needs to have this therapy approved and paid for is their primary care doctor's referral.
Let's say that doctor has examined the evidence, and found reiki to be unsupported for any use. You explain to the patient the correct evaluation and treatment of low back pain, and explain that you will not be making the referral.
The patient is angry. She doesn't want to have to pay for the treatment out of pocket.
What would you do?
Now let's…
sb admin | May 5, 2008I can't tell you the number of people who complain to me about having their hope taken away. Exactly what this means, though, isn't always clear.
Sometimes an oncologist will tell them (so they say) that they have a month to live. Sometimes their cardiologist tells them (so they say) not to travel to their grandson's Bar Mitzvah. Sometimes the spine surgeon tells them their back will always hurt, no matter what. So they say.
Patients tell me a lot of things. I'm not always sure what other doctors really told them, but what is important is what the patient heard. The oncologist might have…
sb admin | May 5, 2008I recently lost a close family member to cancer. She was old, she had been ill a long time; it still hurts. But in her dying, she made some wise choices. She was a very bright woman, and retained her mental capacities right up until the end. This gave her the opportunity to decide how she would approach death. She chose to enroll in hospice.
Hospice is widely misunderstood, partly because of the way we misunderstand death in the U.S. Instead of an inevitable part of life, death here is seen as an enemy to be fought at all costs, no matter the futility. Intensive care units, which were…
sb admin | April 19, 2008Last night I was reading a book to my daughter at bedtime. It was all about a kid who had chickenpox. I looked at my wife and said, "this is a bit outdated."
"So what, it's cute," she accurately replied.
Wow. I hadn't thought about it much lately, but chickenpox in the U.S. is disappearing rapidly. "Pox parties" are gone. Kids aren't missing weeks of school. Pediatric ICUs aren't seeing much varicella pneumonia. Now that I think about it, a number of important lessons I learned in medical school are becoming historical oddities. On my pediatric rotation, we learned to watch for the…
sb admin | April 6, 2008I'm off to the walk-in clinic in a little while. If past experience is a useful guide, I will see at least a dozen people with various respiratory viruses causing colds, conjuntivitis, bronchitis, and sinus infections (offending viruses include adenovirus, rhinovirus, and many others). Generally, the folks giving a home to these bugs need grandmotherly advice. Part of my job is to determine which of these patients might have an infection with Group A beta-hemolytic Streptococcus, Bordatella pertussis, Mycoplasma pneumoniea, Steptococcus pneumoniae, influenza, or other potentially bad…
sb admin | March 29, 2008Urinary tract infections (UTIs) are a very common problem, especially in women. The link provided offers some very good information, but briefly, women's urethrae (the tube the urine comes out of), are closer to the rectum than those of men (who have a built-in "spacer"). This allows bacteria from the colon to creep over to the urinary tract and cause burning, pelvic pain, frequent urination, etc. I treat UTIs daily. Most are uncomplicated, but some are quite serious (usually in the elderly and chronically ill). As medical problems go, I love UTIs. When a healthy, young woman comes in with…
sb admin | March 27, 2008My profession does not allow me the luxury of suffering fools, but neither does it allow me the luxury of always being blunt in my beliefs.
Readers may have noticed a slight tendency toward snarkiness, especially when dealing with woo. I refuse to pull punches when it comes to people peddling quackery. Religion is different.
In my work, my religious beliefs (or lack of them) are irrelevant, and I don't intend to "confess" to either belief or non-belief to my patients. Being a physician is not the same as being an academic scientist. As a bench scientist, your cell cultures don't really care…
sb admin | March 24, 2008Teaching facts is easy. Medical students eat facts like Cheetos, and regurgitate them like...well, use your imagination. Ask them the details of the Krebs cycle, they deliver. Ask them the attachments of the extensor pollicis brevis, and they're likely to describe the entire hand to you. Facts, and the learning of them, has traditionally been the focus of the first two years of medical school. The second two years deals with putting facts into action. Teaching medical students and residents is very different from being a school teacher, something with which I have first-hand knowledge…