Patient Language

The Art of the Interview

''It doesn't hurt, but it's sore.''
The meaning of these ambiguously confused words became more meaningful to me just a few hours after a lecture about carpal tunnel syndrome...
We interviewed a standardized pt who had trouble sleeping and I was the first one to go in my group. It was difficult getting info from him and I felt like it was getting to the point where he was just repeating himself as I rephrased my questions.

So, you're not drinking any caffeine before you go to sleep? No.
No coffee, or tea or anything like that... "Noo," he replies, an edge to his voice belies his grumpiness.
Have you been dozing off during the day? Nope. Hows your energy lvl? Good.

I left the interview frustrated and unsatisified that I didn't establish a good diagnosis... I ended up by concluding that he still needs to get used to his schedule of running in the afternoon instead of his usual morning runs.

Upon watching the review video, I soon learned that he had plenty to say after the simulated patient encounter. "NAPS, buddy!" He growled, shaking his head in disappointment that these were the sort of people training to become doctors.

I felt disappointed. Was I too imprecise in my language? I asked the exact same question as a later person, but in her case, the patient said "Nope. Oh.... wait..... yeah. I've been taking naps." It was this dawning of comprehension that helped him realize the reason he was having trouble sleeping. Was this a question that I should have clarified? Something that I should have twisted around and pursued one last time in the 8 minute time frame I had to diagnose this mystery problem?

Doze:

v.intr.

To sleep lightly and intermittently.

v.tr.

To spend (time) dozing or as if dozing: dozed the summer away.

n.

A short, light sleep.

Phrasal Verb:

doze off

To fall into a light sleep.

---

[Probably of Scandinavian origin.]

Nap:
n.

A brief sleep, often during the day.

intr.v. napped, nap·ping, naps

1. To sleep for a brief period, often during the day; doze.

2. To be unaware of imminent danger or trouble; be off guard: The civil unrest caught the police napping.

---

[Middle English, from nappen, to doze, from Old English hnappian.]

via FreeDictionary.com


Perhaps the old man was getting into the patient "denial rhythm." Is this wrong? No. How about this, this and this? No, no, no. This? NO! Perhaps he didn't hear the question. Perhaps he was waiting for the keyword "Nap" and "Doze" wouldn't do.

Perhaps it was my fault. I might have waited a little bit longer after asking him about dozing off... about his energy level during the day... about the amount of sleep he gets each night (and perhaps clarified over a 24 hour period.) I could have used the word nap and been much more satisfied with my performance.


Perhaps it is for the best that this was a make-believe patient and I am still a make-believe doctor. I still have plenty to learn and I hope that these small little errors will continue to bother me enough that I can distinguish these little patient language intricacies that will guide me to the right diagnoses.

Medical Student Mentoring

Four years ago, I was a pre-med student. I joined a new group just starting up, filled with medical students eager to mentor young fledglings like myself. It was a bit rocky in the beginning and I was paired up with a mentor in his 3rd year. He was so busy in his clerkships that I only got to see him once -- he didn't make it to any of the planned activities through the year. I ate lunch with him once and he intimidated me. I expressed an interest in Doctors without Borders and I got a lecture about how it would be all work and no fun and basically, a waste of time unless I liked to volunteer and acquire larger debts from idle school loans that would be harder to pay off.

It was after that encounter that I made a resolution. If... no... When I became a medical student, I would strive to be an encouraging mentor. An "inspiring, down-to-earth and good storytelling" mentor, as I wrote in my Personal Statement earlier this year.

This past Friday we had our mixer for the mentors and mentees. I gave a little speech in which I talked about the transition from being a pre-med to being a med student. I talked about being challenged enough to be "whelmed" as opposed to overwhelmed. I also quoted Stephen Colbert, a witty fake-news commentator on Comedy Central. He gave a commencement speech that I found online and I really enjoyed it. I've spliced it up so hopefully it'll be enjoyable for you too.

Say “yes” as often as you can. When I was starting out in Chicago, doing improvisational theatre with Second City and other places, there was really only one rule I was taught about improv. That was, “yes-and.” ... To build a scene, you have to accept. They say you’re doctors—you’re doctors. And then, you add to that: We’re doctors and we’re trapped in an ice cave. That’s the “-and.” And then hopefully they “yes-and” you back... It’s more of a mutual discovery than a solo adventure...

Now will saying “yes” get you in trouble at times? Will saying “yes” lead you to doing some foolish things? Yes it will. But don’t be afraid to be a fool. Remember, you cannot be both young and wise... Cynicism masquerades as wisdom, but it is the farthest thing from it. Because cynics don’t learn anything. Because cynicism is a self-imposed blindness, a rejection of the world because we are afraid it will hurt us or disappoint us. Cynics always say no. But saying “yes” begins things. Saying “yes” is how things grow. Saying “yes” leads to knowledge. “Yes” is for young people. So for as long as you have the strength to, say “yes.”

And that’s The Word.

I enjoy "yes-and." Some might say that it is sucking up... just like some people call BS on corny or cliche things. Funny how cynical that sounds. :) "Yes-and" is about enthusiasm and participation. That's the side that I want to focus on.

I also organized some mixer games for the group. My favorite one was a "Coat of Arms" with a blank shield emblem split up into four parts. Everyone was directed to draw something about themselves in each of the quadrants:

1. My "Great Doctor" Quality
2. My Medical Quirk (something weird about themselves that they were willing to share)
3. Favorite Pastime
4. Favorite Food

My personal experience with "thinking" icebreakers is that people don't really want to work too hard at them... so I tossed in the last two categories as an easy gimme. The mentors all stood in a circle facing outwards and mentees stood around them and they got to talk for about 2 minutes or so to get to know each other. It was successful... perhaps too much so, because people ended up just chit-chatting towards the end.

Here's the file if you ever want to try a similar activity!

And in case you were curious...

1. I drew a picture of an open book. Partly because I'm so open, but more so because I love stories. Doctors get to hear the most interesting and intimate stories people can tell... and they have to turn them into something relevant in their 15 minute visits! Wow.
2. Hyperhidrosis. I've mentioned it before. I drew a stick figure with a blue marker, dripping from the hands and an arrow pointing to a guy with cartoony sweat flying out of his head.
3. I drew a wizard with a green robe and a magic wand. I love to play role-playing games. It feeds my addiction to stories. In particular, I love to play Dungeons and Dragons.
4. I drew some shrimp diving eagerly into a cup of cocktail sauce. Mmm... shrimp. The tasty "cockroaches of the sea," as one of my seafood-ophobe friendswould so delicately put it.
   

My Personal Statement

Dr. L entered the room as my heart anxiously pounded. I hesitated before shaking hands with him, not because I was entrusting my life in his but because I knew my hands were cold and clammy. "This will be the last time I'll have to shake someone's hands like this," I said with a grin. He had told me how the procedure would work: the sympathetic nerves of Kuntz would be severed to alleviate my hyperhidrosis. Although the surgery itself was quick, it changed my life drastically. I knew then that I wanted to be a doctor. Even though I now had the confident hands of a doctor, I needed more to actually be one. With my new hands, I started working on gaining the head and the heart of a doctor as well.

My critique: I'm sure many applicants have struggled as I did, trying to tighten prose without losing the context. Just to clarify, I had a bithoracic sympathectomy (video link), a surgery to cure palmar hyperhidrosis. I was disappointed that I couldn't adequately explain "hyperhidrosis"... it would have taken too much room to explain it. The people who read it caught on well enough, so that was good to hear. I could only hint at the details I really wanted to cover. Now that I know a little bit more, I'm embarassed to say that the facts are minorly incorrect too. The entire sympathetic chain was severed, not just the weird excess Nerves of Kuntz... but I tossed that in because it sounded cool.

Looking back at this PS makes me wince. This is what got me into medical school? Granted, it was a significant improvement over my opening statement from the prior year (which had the same gist, except I didn't make the hands/head/heart connection until the end of my PS.)

The poetry of gaining the hands of a doctor from a thoracic surgeon was something that I would have liked to elaborate on. I didn't see the doctor very often as a child, but palmar hyperhidrosis was something that I had been dealing with since 2nd grade.

You might be asking yourself: What's the big deal about sweaty palms?

Well, we're not talking about damp hands like someone who is just nervous. Yes, my sweaty palms were triggered by nervousness too, but we're talking about minor anxiety triggers. And it wouldn't go away... I would have to deal with sweat dripping off of my palms for the rest of the day. Imagine washing your hands and not drying them off afterwards. That's how my hands would be at their worst, mere seconds after I would wipe them on my jeans.

I would have to wear jeans everyday and a light colored shirt otherwise sweat stains would show on my thighs and armpits. My hands would freeze in cold weather, because the sweating just... kept on going.

Paper was my adversary. I would ruin books just by holding them and flipping the pages. I needed a folded up pad of paper to soak up the sweat when I took notes in class. My computer keyboard and mouse were all gummed up. I was afraid to touch anyone, especially girls, afraid of their barely concealed looks of disgust; I was afraid of intimacy.

I knew it would be a hindrance in pretty much any profession that did something hands-on, from social handshakes to labor-intensive crafts. I was concerned about shop, art and especially science LABS. Putting on gloves is a nightmare with damp hands. Wiping off equipment after touching it is annoying and disgusting.

I'm sure you get the point by now, after my woe-is-me story.

It was amazing to me that a decade of grief was wiped away after a same-day surgical procedure! I had tried so many other things, like topical antiperspirants (Drysol) and even palmar electric shock (Ionophoresis).

In typical understated doctor-speak, this surgery "improved the quality of my life."

I was inspired by the changes I saw in myself... something so minor that had such a large effect on the rest of my life and what I could do with it. I felt a newfound confidence from it, free from social anxiety and frustrating note-taking.

I was ready to make the same changes with other people. I wanted to become a doctor.

Despite the rough and clumsy nature of my opening paragraph, perhaps the admissions committee saw my PASSION and my . To you aspiring applicants, that's what you should put in your words. Share yourself and share your passions.

Should suicide be legal for people in pain?

I am on OkCupid. While I will admit that I like looking at profiles of people who "match" with me, I am not in the right emotional state to start dating again, since my last girlfriend broke up with me a week through med school and moved to Japan to teach high school English. Ah, but don't feel too bad for me... we talked about it for months and I couldn't convince her to maintain a long-distance relationship together.

I like taking the tests on OkCupid... but I don't really like answering the polling questions. I recently learned that they added some features, allowing you to blog about the questions so you can argue some of the points... and I realized that many of the ones I have problems answering are the medical-ethical ones! Here's my latest entry on suicide:

Should suicide be legal for people in pain?

• Yes
• No

Technically, suicide IS legal, because you can't punish someone who is already dead. Also, we probably should limit this question to "physician-assisted suicide," aka PAS, since that is likely the issue that the question is intended for.

So the question becomes: Should it legal for doctors to help patients in pain commit suicide? My first liberal inclination is to say yes, however, the term "pain" must be defined.

Are we talking about someone with emotional pain? Did they just get dumped?
Are we talking about someone with physical pain? Did they just hit their knee?
Are we talking about someon with spiritual pain? Uh... I don't even know what this would be.

Are we talking about someone with an incurable medical condition which causes them intractable pain and they have 6 months or less to live? Cancer patients, very old people (who have "failed to thrive") and perhaps a few other special conditions may apply.

People have a right to death with dignity (DWD) in OR... perhaps the gentle euphemism encouraged the proposition to pass in 1994 and again in 1997 under the name Pain Relief Promotion Act.

There has been efforts to have DWD approved in HI also, under the last set of conditions listed above. Since 2000, less than 50 people die with dignity as many go through a process screening for depression, coming up with alternate palliative measures like increasing pain medications, encouraging family support, etc. That is only 0.0014% of all deaths in Oregon.

This is a rare situation... just because people like Dr. Kevorkian abuse the system and commit ethically and legally unsound acts doesn't mean that Death with Dignity should be a rule.

Everyone wants to die with dignity, surrounded by the people who care for them. However, physician-assisted suicide should not be a RULE. However, I strongly believe that there should be EXCEPTIONS.

More to come.

Funny, how fickle fate falls

Michael started off at Cal Poly as a triple major, acquiring credits in political science, history and liberal arts over the course of 5 years. He paid his own way through college, despite having affluent parents and he was determined to do things on his own. His pride might have cost him in the long run, but his strong sense of independence and led him to his current unique situation and changed his life for the better. He had big dreams of moving to My State and becoming a manager of a major hotel, "just another white guy moving in and taking over," he added jokingly. After graduation, he left his friends and family with a mountain bike and $400 in his bank account to begin his life anew.

He applied for jobs all throughout town. As an articulate college graduate with strong grades and an excellent resume, it should have been easy for him to find a job. He was involved in student government representing the small liberal arts community at Cal Poly. His friends regularly came to him asking for help with their papers. Still, he had no luck getting a job.

After a few weeks of job searching, he finally found a job working at Jamba Juice. Ironically, his friends back home in San Luis Obispo founded the company that he found himself working at... and he kept grinding away at his job applications. After a year or so, he found himself another job at Sunset Grill. Just a few weeks into his job, he developed a pounding headache and he called in sick to work. Two days later, he was in the hospital and unbenownst to him, he was fired from his job. It turned out that he had a pituitary tumor and he had no health insurance.

Queen's Hospital treated him well and they removed the tumor. Lucky to be alive, he found himself with new problems. He was going to get kicked out his apartment in a week and he had no job, no money, nowhere to go. He applied for jobs, but still, no luck.

On a Tuesday night at 2:00 am in the morning, he found himself in front of the Institute of Human Services. The homeless shelter's caretaker was hesitant to let him in. Dressed as he was, with neatly pressed slacks and a collared shirt, talking the way that he did with a polished educated voice and looking the way that he did (white and privileged,) he might have run into problems. It was recommended that he go back to the area that he came from and find a place to stay. That bike ride back was a tough one... he suddenly saw the people sprawled out underneath trees in the shady parks, in the back alleys of paradise. These were people that he had once thought disparagingly of. "Clean yourself up, shave and get a job!" These words now had a biting sense of shame since it was something that had happened to him.

Michael was too ashamed to contact his family. He did not want to be thought of as a failure. He would pull through on his own... and because of this decision, he became a stronger person. He learned a lot about himself. He learned more about life from his fellow homeless than he did in college.

He found himself an alcove behind a church to sleep at. And it began to rain. For more than forty days straight, it poured rain of biblical proportions. Yet he was grateful for the rain... it limited his chances of being discovered by people and removed from the church grounds. He read the newspaper everyday and learned about other homeless people getting kicked out of Ala Moana park. How they had no where else to go, but a few churches had been sheltering them until a more permanent solution could be found.

A janitor had found him sleeping in the alcove one night and gave him a blanket, for which he was grateful.

Michael had fallen in between the cracks. Down on his luck, he had to stand in long lines for food alongside other homeless people in downtown... as cars of young healthy people whizzed by, talking on their cell phones and sipping their morning coffee.

A few weeks later, the janitor struck up a conversation with him about the Ala Moana homeless. "I read about that in the newspaper," he said. "They are all staying at Central Union Church, right?" The janitor laughed and gestured around. "This IS Central Union Church." For weeks, he had been sleeping, starving and freezing outside while there was a bunch of homeless who showed up every night to sleep, eat and keep warm inside the church!

He was part of the initial exodus that was transferred to the homeless shelter just a few blocks from My Medical School.

A man from a church group recognized Michael's potential and he was soon hired to work in the program Helping the Hungry Have Hope.

And that's what brings me here today. He said, wrapping up his story for our class.

I was touched. Here was a man who did nothing wrong, yet he still found himself quickly abandoned by society. He could have died in California, lacking health insurance, but he didn't. He could have given up on life, but he kept trying and trying and trying.

He was the same age as all of us... he could have been a medical student. We could have been homeless. I remember in high school how I wanted to be homeless. My ideas were closer to "hoboism", riding trains and finding oddjobs, instead of the harsh, insecure realities of homeless life. Worrying about where your next meal will come, whether or not you could find a safe place to sleep for the night, trying to avoid becoming a victim of violent crimes.

Homeless people have parents who wonder what happened to their children.
Homeless people have lives and goals no different than our own, but they lack the means to achieve many of them.
Homeless people have sob stories to beat anything that someone who has job security and a home could possibly say.

They need to know that people care. Then, they can be helped to help themselves. They can be given a sense of purpose and be proud of their responsibilities. It all starts with someone to listen to their story, learn more about their priorities and be nonjudgmental about their values.

I'm sure Michael will contribute great things to society and he can give hope to others like himself.

Pity for a Pass

Dave Attell is a comedian who used to be on the show Insomniac, where he bummed around bars in the middle of the night all around the U.S., filming his crazy exploits. In one of his stand up shows, he said "You know who I like to make fun of?!?!?"

"Amish people. That's right... they can't get offended seeing me on T.V.... they are never going to know!"

The same can't be said of the people at the homeless shelter I visit twice a month. You'd think that they are out of touch with the world around them, but they scrounge up the money for the television!

I turned my attention away from the cubicle with the family watching cartoons on repeat back to the patient at hand. He was equally distracted, flipping his cell phone open and closed absent-mindedly while the third-year medical student taking his case consulted with the family medicine resident.

"So he came in with this EKG and said that you'd sign off on his bus pass..." the MS-III said in a tired voice. It was close to the end of the clinic time, 9:15 pm, and Thursdays went on for far too long for him.

There was a problem, though. The rules and regs for getting a disability bus pass are such that you need to qualify by having difficulty with one of the following:

• negotiating a flight of stairs, escalator, or ramp;
  
• boarding or alighting from a City transit bus;
  
• using the City Transit bus due to confusion or disorientation;
  
• reading informational signs; or
  
• walking more than 200 feet.

His EKG read "sinus arrhythmia." Unstable heartbeats aren't on the list of "things that get you a cheap bus pass," so he was claiming that he often "gets confused about which stop to get off at, etc."

The family medicine resident wasn't too happy about the situation. Obviously she had given the patient the impression that she would for sure sign off on his bus pass. We all sat down with the patient and she went through a long discussion with him about his past... what led him to homelessness... and he had been discharged recently from the military. There were some stipulations about his heart condition that complicated his health benefits with the military and he had been in Iraq for a while.

We went through a psychological assessment and she felt that he might be having suffering from Adjustment disorder and he needed some time to sort things out.

---------------------------

This is the point where I thought long and hard about the ethical issue at hand. Here's a guy who wants a cheap bus pass. He's only going to be using it for a short period of time while he gets adjusted and as a homeless person, it would help him out big time, since public transportation costs a pretty penny. However, fudging the data on his bus pass is a risky move. Doctors sign off excuse slips for sick patients all the time... could this be any different? What are the legal consequences of claiming that this man is disabled? He's a veteran for sure, rejected by the military no less. And that put him out on the streets with a bad heart. Surely a little pity could go a long way.

Nuh uh. I wouldn't do it.

Would you?

The Seal of NMSO

As if this site needs an Official NMSO seal... but here it is anyway!

Get your own free personalized seal here:
http://www.says-it.com/seal/index.php
Make it as funny or as professional as you'd like!

via Aetiology

The Cranberry UTI Connection

Last year, I shadowed an FP around her rural clinic. It was very educational and I'm willing to bet that I've forgotten more from her than I learned from medical school so far. ;-)

A lot of the most educational bits did not necessarily come from my interaction with her; rather, they came from my interactions with her patients. I can remember one in particular, when I was reading about "Woo" on Respectful Insolence. This lady came in for a routine checkup and she brought up the subject of frequent urinary tract infections.

"I've been doing a little research online..." she said.

Little red lights and alarms started going off in my head. Bweep bweep bweep! This is probably going to be something a little wacky... prepare yourself!

"And I started taking supplements of D-mannose. My urinary tract infections disappeared soon after that!"

Here's the simplified process of the urinary tract infection. Bacteria from the environment gets up into the ureter through the urethra. This is more common in women than men because guys have longer urethras (hehehehe... I'm still immature and I need to giggle a bit at that thought.) So male "hoses" are a protective mechanism preventing bacterial infection. One type of bacteria that normally infects the ureters is E. coli. No, not the nasty ones that people die from that cause bloody diarrhea and death... just your plain jane bacterial buddies that hang out in everyone's gut. The female anatomy is not well suited to prevent the bacterial transfer from anus to urethra... and that's a reason why female hygiene is so important!

E. coli can only fasten onto human cells if it has the right proteins and sugars to use as grippers. Special strains of E. coli with grippers aka type I pili that can bind mannose can climb more easily into the urethra from their old hangout spots. They get to relax and stretch out in their new home... but the body doesn't like it too much and that causes pain, redness and frequent urination.

Anyway, I wanted to talk about D-mannose. So, the lady hands the FP a small little packet that she printed out on these supplements. Without so much of a glance, the FP takes it and tosses it on her chaotic nest called a desk. I look at it and notice that the website is buyalternativemedicines.com or something like that and I think nothing of it. Obviously, my FP didn't think it was anything worth mentioning to me... but I had wanted to learn more about it.

Does D-mannose turn the urinary tract into a sudden slip and slide for the E. coli bugs and wash them out? I tried to do a search on the efficacy of D-mannose pills on PubMed, but my uber-search skills were limited last year.

What does this have to do with cranberry juice? Well, cranberries are chockful of indigestible sugars like D-mannose!

Yesterday, I revisited the cranberry, D-mannose, UTI connection that I had previously dismissed and I was pleasantly surprised to find that there have been some studies done that have shown minor improvements in the prevention of UTI with cranberry juice and cranberry pills. However, I personally think that better awareness and hygiene would be a better alternative to drinking nasty stuff like cranberry juice. Yuck! It's a bit too bitter for my taste. Apparently, those E. coli think the same way.


References
Jepson, R.G. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2004;(1):CD001321.

P.S. I put up a brief version of my findings on Wikipedia under mannose.

P.P.S. [edit 9/12/06]
According to Biotech Weblog, here's a few more things tha cranberry juice can do because of the tannins in the drink as well:

* They change the shape of the bacteria from rods to spheres.
* They alter their cell membranes.
* They make it difficult for bacteria to make contact with cells, or from latching on to them should they get close enough.

Wow! Sometimes its the simple stuff that I find most surprising in my learning of medicine.

Women's Health

Here's a collection of links on how to perform the female physical examination.

OBGYN-101 is a great clinical resource for everything related to women's health; fact cards, sample progress notes, how to perform procedures, etc.

Harvard Medical School has a Virtual Patient Reference Library with a "Woman at midlife", covering Physiology of the Menstrual Cycle and Menopausal Transition, Effects of Postmenopausal Hormone Changes on Target Tissues, Assessing and Discussing Risk with Midlife Women, Screening and Preventive Practices for a 50 Year-Old Woman, Breast Exam, Pelvic Exam, Guidelines for Postmenopausal Hormone Replacement, Abnormal Genital Tract Bleeding.

UCSD's Practical Guide to Clinical Medicine has a portion on the breast exam, and UCLA's Fundamentals of Clinical Medicine has both the breast and gynecologic exam.

More generally, MedlinePlus features Interactive Health Tutorials for patient education.

Four A's of Smoking Cessation

A sk

• ID all tobacco users at every visit.
• Determine exposure to environmental tobacco smoke at home/work.
• ID patients with nicotine addiction.

A dvise

• Provide a strong, clear and personalize message urging them to quit.
• Review the benefits of quitting and risks of continuing.
• Assess their willingness to quit.

A ssist

• Have the patient develop a quit plan
• Set a quit date
• ID sources of support for cessation (family and friends)
• Remove tobacco and other cues from the home and work environment
• Provide counseling, informational materials and other behavioral interventions.
• Recommend use of pharmacotherapy
• SR bupropion
• Nicotine gum
• Nicotine inhaler
• Nicotine nasal spray
• Nicotine patch

A rrange

• Provide a reminder on the quit date.
• See patient shortly after the quit date to ensure success.
• If unsuccessful, ID barriers and methods for their removal.
  

via the National Cancer Institute

Know your ABC's of heart attack treatment

A spirin (Anti-Anginal)/Atenolol
B eta-blockers and BP
C holesterol and Cigs
D iet and Diabetes
E ducation and Exercise