On oops disclosures

Dr. Michael Wilkes's Second Opinion on KCRW on disclosure.

I've commented with my thoughts on disclosure of a cancer diagnosis to a Japanese patient before in "Shh! He doesn't know!" Culturally, it is acceptable for the family to request that this information be withheld from the patient -- something that I found ethically repugnant a year ago.

If a patient asks "why am I getting this treatment", is the family asking us to lie for them? How far is this betrayal of trust expected to go?

However, my recent visit to Japan made me reconsider this. There is a trend in Japan towards more Western values and practices in Medicine (among other things) and cancer disclosure is still a contentious topic there. I asked a few doctors (one was a cardiologist, the other, a resident training in GI) how they approach the subject.

The resident told me point blank that he followed the family's wishes and didn't tell the patient. He echoed the sentiment "a lot of patients cannot handle a diagnosis of cancer." I was surprised to hear this. Cancer isn't the death sentence that it used to be. The elder cardiologist agreed with me and told me that he tells his patients regardless of what the family wants. "It's their right to know," he said. Of course, he did have training in the U.S., so that might have affected his cultural judgement.

I'm not sure how I feel about the situation mentioned by Dr. Wilkes. If I were the surgeon, what would I do?

*deep inhalation*

I'd like to think that I could do the right thing and respect the family's wishes while still fulfilling my role as a doctor. Before the diagnosis is even made, I would like to approach the patient and tell him/her "now, one of the things we are testing for is cancer. If it turns out to be cancer, how would you like this to be handled?"

This gives the patient an opportunity to "opt-out" and puts patient decision-making in the hands of the family. I think this is culturally sensitive for both parties and it has the advantage of forewarning the patient of their potential diagnosis. If they are keen, they probably suspected cancer all along. Perhaps it's just reassuring for some patients to know that they are being taken care of as best as possible without having to worry about the prognosis.

Ankle Sprain

Monday was my first day back at school and I've jumped headfirst into learning!

There was a case presentation on someone who fell down and broke their leg. Just a few hours after that, I was running around and I slipped off a stair and rolled my ankle. It was already weak to begin with because I had injured it before. Musculoskeletal problems and rehabilitation all of a sudden became more interesting to me. :-)

I applied the RICE treatment for my ankle on the first two days to control the swelling and pain.
R = Rest as much as possible
I = Ice, for 15 min, twice a day
C = Compression, with ACE wrap, wrapping twice around the foot first to secure it, then alternating in figure-8s around the foot, overlapping by at least 1/3
E = Elevation assists with drainage

My biggest question now is: what can I do to prevent this from happening in the future?

Here are some of the exercises I am supposed to do twice a day as 3 sets. (Whoa! That's a lot more rehab than I expected.)

• Sit on a firm chair or stand up. Loop one end of surgical tubing around the ball of the foot with the injured ankle. Hold the other end of the tubing in your hand. Put your heel on the floor. Stretch the tubing by pushing down with your foot, the way you push on the gas pedal of a car.
• Sit on a firm chair or stand up. Loop one end of the tubing around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by pulling up with your foot (lifting up your foot), using your ankle, as if you were trying to pull the table toward you. (This motion is the opposite of trying to "step on the gas.")
• Sit on a firm chair or stand up. Loop one end of the tubing around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by moving your foot out to the side, away from the leg of the table.
• Sit on a firm chair or stand up. Loop one end of the tube around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by moving your foot to the middle, toward your good ankle.

Exercises and advice by "How to Care for Your Ankle Sprain" 10/1/2002. American Family Physician.

Curves of Paget's Disease

Paget's disease, aka osteitis deformans, is a "hot" disease of bone, where your bones are first degraded faster than they are built, then they recover, but in a strange and brittle way. Normally, your body is in a constant state of flux that remains relatively balanced -- unless you're vitamin D deficient (leads to rickets or osteomalacia), estrogen deficient (postmenopausal osteoporosis), etc.

A year has passed...

I've completed a full year of medical training and the biggest lesson that I've learned is that I don't know much.

The first patient that I saw with a group of my peers was last year, about this time -- we had just finished learning how to ask a patient about their past medical history and their background information. Our interview with an 80 year old woman turned into a recounting of her personal story, how she came to the state, worked in the fields, raised three children, survived two heart attacks and pneumonia last year. Other parts of her story came out in more subtle ways. She was able to recall details of her past perfectly -- but more recent memories from last week's procedures that brought her to the ICU were more fuzzy. It turned out that she had been diagnosed with Alzheimer's... our preceptor commented how it was therapeutic for her to reflect on her past with us.

This theme stuck with me as I learned more and more how the greatest gift I could give a patient, here and now, is my time and understanding. A lot of doctors are stressed out and they are only given a 15 minute window to see patients! As a "non-essential" part of the medical team, I have the luxury to spend more time with the patient.

I have volunteered at a homeless shelter providing free medical care and we recently expanded our services to another shelter. Time and time again, I have been drawn into a patient's story that went beyond their chief complaint to their underlying condition... how they lost the security of a warm bed and home to call their own. One man came in because of bedbug bites. He used to be a prize-winning chef, but he screwed it all up selling drugs. He was caught and went to prison for a little while, but when he got out, he found out that no one would hire him because of his prior conviction. In his despair, he confessed to me that he had a child on the way and if he was missing from the shelter in a few weeks, it's because he's back on the streets dealing drugs. I asked him about what was important in his life... he said that it was his girlfriend and their new child. I told him to think about the life that child would have and how much more difficult it would be if he were a drug dealer. He ranted on for a while and the visit went on for close to an hour. He said that he felt better afterward. I was glad that I listened to him... and I hoped that he listened to me. I saw him a few weeks later still at the shelter, but he has a black eye and the white of his eye had turned blood red. I hope beyond all hopes that he hasn't resorted to crime and drugs again.

Recently, I saw a series of patients in the clinic that really made me realize how much my volunteer work at the shelter has changed my outlook.

- difficult man

- emotional, obese woman w/ recent dx of DM

- possibly drunk & pregnant woman w/ a painful boil on her thigh - worried about baby!

What makes a good doctor?

When you find the answers to this question, you will have found yourself.

One of the most touching parting gifts from my ex-girlfriend before she left for Japan and I went to medical school was a simple project: she gave me a red ribbon and a bunch of colored construction paper squares with slits cut into them so they could be threaded on. The quote above was written on the front with the query "What makes a good doctor?" and the assignment was one that I took to heart.

Now, when I came across something difficult in my journey, something that I found worthwhile enough to blog about, I also try to summarize it on a colored square to hang on the red ribbon. This art project is a constant reminder to me of the important lessons I have learned. This entry will be my electronic file of my ponderings as I journey to find myself.

1. Being Proactive: I drew blood during my first week of medical school! The act of being proactive is not about being aggressive or stubborn, it is about being open and willing.
2. "Yes-And": Stephen Colbert's commencement address on improvisation, silliness and refusal to become a cynic
3. Competence: Strive to be your best, but don't fret about your inadequacies!
4. Motivation: a nephrologist preceptor told me "95% of being a good doc is how badly you want to be good."
5. Sacrifice: Make the most of your spent time and energy - make it meaningful
6. Ask an unscripted question
7. Resist complaining, stay positive
8. Count something
9. Write something
10. Change
    

Fwd: FW: New Medical Student Org

I was sent this in the mail today and I thought I'd pass it along. I am quite hesitant about "hanging up my shingle" so to speak, because of the intimidating business logistics involved. How much time would I actually spend with patients? Should I join a physician group so I don't have to worry about starting from square one and hiring all the staff? Should I set out on my own so I can be completely independent? Would I be happy with that?

I have no idea what problems lie ahead on this path to primary care. And I'm glad that a student organization has set out to tackle some of these worrisome issues.

You came to medical school to acquire the knowledge and technical skills necessary to make your mark in the world of medicine – but when you leave, will you be equipped with the right tools to make the important career decisions in your near future? Given the increasing financial pressures on the practice of medicine and the growing medical student debt load, today's medical graduates are navigating a more complex terrain than ever before. We owe it to ourselves and to our future patients to make informed decisions about how we choose to practice medicine.

The Business of Medicine (BOM) is a student-run, non-profit organization that was founded in 2006 by medical students at Georgetown University. BOM's mission is to increase medical student awareness of financial challenges and opportunities impacting the practice of medicine. Simply put, we recruit thought leaders and experts to speak at medical schools. Topics covered include Financial Planning, Residency Selection, Post-Residency Career Paths (private practice, hospital-based medicine, academic medicine, etc), Reimbursement, Health Insurance, Medicare/Medicaid, Physician Income and many more.

BOM also maintains a website with links to the most high yield resources on Debt Management, Insurance/Policy, Malpractice, and Career Development. Each link posted has been screened by medical students to provide the most concise, relevant, and accurate information available on the topic. We invite you to explore our website at: http://www.businessofmedicine.org/ and hope that it will help save you time in the future. We welcome your comments and suggestions for improvement as we continue to develop and keep our site up-to-date. It is truly a site for medical students by medical students!

You've invested valuable time, energy, and financial resources into the process of becoming a physician. We invite you to join us in our mission to bring BOM to medical students nationwide and to empower yourself by learning how to best protect this investment.

For more information about how you can get involved, please contact us at bom@businessofmedicine.org. We look forward to hearing from you!

Time-tested science

A publication for every fact, a life for every arrow.

This is just something I've been pondering for a while... all throughout my studies, I come across piles and piles of research which must be quickly "triaged" into a read, file, or discard category. So much research goes into each simple little fact in a textbook, demonstrating a link from A->B. Someone could devote their entire life towards this modest goal, because there are so many different methods of experimentation!

My embryology teacher in undergrad put it best as "show it, block it, move it."

1. Show it: First things first. You need to run epidemiological studies, immunofluorescence studies, etc. to show that a certain gene/enzyme/disease/factor is present in association with whatever you're studying. And you need to do assays, dig through piles of charts, or run huge randomized polls of selected populations...


2. Block it: Then, you can stop it. This can be tricky in some cases. You need to demonstrate that a disease/condition/observation disappears in the absence of the variable you're tweaking.


3. Move it: Then, you can move it. Can you create the disease/condition/gene product with the modest introduction of your tweak somewhere else? This is the most ethically questionable of the three principle study designs, since you cannot induce diseases in humans and expect to get away with it. Often, animal studies are performed with the hope that it can apply to other models as well.

Three simple concepts. Yet the execution of them can take trial after trial, assay after assay, tons of paperwork to get funding and support and recognition.

I'm surprised sometimes that scientific progress hasn't halted altogether, given the amount of work, time and money it requires. I have a great appreciation for the unsung heroes of the laboratory whose obscure brilliance might only be recognized by a super-select few. (Few? Can I even use that as a noun? It sounds okay to me.)

Writing a Personal Statement

This is the most difficult part of any application -- the free and creative portion in which you distill your essence into something that falls within the 5300 character limit.

How do you do this? I've talked about my own personal statement in the past.

TheReporter has some other tips and thoughts on writing a personal statement:

Humility and honesty that must come out in your essay.
A successful personal statement FOR MEDICAL SCHOOL is about the patients, and their perceptions/feeling, more than anything else. Try this before you do your next draft: describe a patient's experience/thoughts, from the first person viewpoint, from the time they first suspect they are ill to the time they see a doctor.

This goes beyond a mere essay to get into medical school. We're talking about a philosophy on how to approach patients. How a doctor ought to use the Golden Rule. This is a life-long concept... and what TheReporter is really doing is asking -- are you the type of person who has enough social intelligence that you can put yourself in someone else's shoes? How did that make you feel?

Writing a personal statement is not about echoing the tired cliche of "I want to help people" or "I want to be like Dr. X and Y because they changed my life." A personal statement should be a personal revelation with emotional content that makes people tilt their heads and go "hm..." Find your personal character flashback moment.

Strive for insight, but don't push the boundaries and make bolder claims than you can support. Practice expressing yourself. Take chances and open up with a patient when you reach a point of awkward silence when they wonder why you're in the exam room. Smile. Laugh. Ask questions. Creating experiences will inevitably lead you down a road that you can look back on and say "wow, I've got a lot of material I can draw on for a personal statement."

Healthcare Blogger Code of Ethics

I just came across this concept through Nick Gene's Pre-Rounds Interview with Dr. Lei of Eye on DNA.
Med Blogger Code of Ethics:

1. Clear representation of perspective - readers must understand the training and overall perspective of the author of a blog. Certainly bloggers can have opinions on subjects outside of their training, and these opinions may be true, but readers must have a place to look on a blog to get an idea of where this author is coming from. This also encompasses the idea of the distinction between advertisement and content. This does not preclude anonymous blogging, but it asks that even anonymous bloggers share the professional perspective from which they are blogging.
2. Confidentiality - Bloggers must respect the nature of the relationship between patient and medical professionals and the clear need for confidentiality. All discussions of patients must be done in a way in which patients’ identity cannot be inferred.
3. Commercial Disclosure - the presence or absence of commercial ties of the author must be made clear for the readers. If the author is using their blog to pitch a product, it must be clear that they are doing that. Any ties to device manufacturer and/or pharmaceutical company ties must be clearly stated.
4. Reliability of Information - citing sources when appropriate and changing inaccuracies when they are pointed out
5. Courtesy - Bloggers should not engage in personal attacks, nor should they allow their commenters to do so. Debate and discussion of ideas is one of the major purposes of blogging. While the ideas people hold should be criticized and even confronted, the overall purpose is a discussion of ideas, not those who hold ideas.

I agree with these ideas, especially those about Reliability of Information. There's so much garbage out on the internet that obscures the truth... it's important for health professionals to ensure that they are providing a refuge from this refuse!

The New News (Google Comments & my own)

A story recently came out about Baby Einstein in the newspapers. They cited the "Journal of Pediatrics" for publishing a story on the paradoxical effect of educational DVDs with children under 24 months. These infants understood fewers words than children of parents who read to them, according to Clinical Cases and Images. CCaI went on to claim that many official news sources failed to link their online articles to the original study and in fact, the Archives of Pediatrics & Adolescent Medicine was the publisher.

However, when I read the article that CCaI posted, it did not coincide with the information suggested in the original articles. It proves CCaI's point though... check your sources! ;-)


In related news, google news is adding the ability to comment on news -- if you are a part of the news story. This has the potential to provide rebuttals (as seen by McDonald's in response to astudy that kids find carrots and veggies wrapped in McD packaging tastier). It has the potential to provide further information DIRECTLY FROM THE SOURCE (as seen in the FDA approval for a new HIV-drug Selzentry.)

I think that the internet will revolutionize how we receive our news. After all, I learned about all of these stories through Clinical Cases and Images... a blog targetted to educating IM residents in the Cleveland Clinic. Unless traditional newspapers can adapt, adopt and become adept with new technology, they will swiftly find themselves outstripped by other alternative news sources.


[edit] Hm... Medgadget provides a little more info from the original Times article, confirming CCaI's reference.

Led by Frederick Zimmerman and Dr. Dimitri Christakis, both at the University of Washington, the research team found that with every hour per day spent watching baby DVDs and videos, infants learned six to eight fewer new vocabulary words than babies who never watched the videos. These products had the strongest detrimental effect on babies 8 to 16 months old, the age at which language skills are starting to form. "The more videos they watched, the fewer words they knew," says Christakis. "These babies scored about 10% lower on language skills than infants who had not watched these videos."

However, the article does not make the bold claims that the authors suggested... or maybe I'm reading it wrong.

Television and DVD/Video Viewing in Children Younger Than 2 Years
Frederick J. Zimmerman, PhD; Dimitri A. Christakis, MD, MPH; Andrew N. Meltzoff, PhD
Arch Pediatr Adolesc Med. 2007;161:473-479.Time Magazine reports on the findings that the popular Baby Einstein video series, meant for infants, lacks scientific merit when it comes to spoken word, and seems to actually do harm.