Charts

My summer work involves helping an orthopedic surgeon with some chart research. Here are couple of things that I thought were funny.

"patient appears to be significantly older than she claims"

I love how every patient seems to be described as pleasant. For instance, "Jane Smith is a pleasant young lady who presents to my service with..."

Referencing a 50+ year old: "The patient is here with her parents."

On a surgical note there always has to be a diagnosis. So commonly you would see something like "Diagnosis: left distal comminuted fracture of the radius." But because you need a 'diagnosis' for every procedure, when someone is just having surgery to remove plates and screws the diagnosis reads "Retained Hardware." As if some patients' hardware magically disappears when they no longer need it, while others have to come back for surgical removal.

For some reason it seems that doctors need to go over the top in thanking referring doctors. Many read like this, "Dr. Smith kindly/graciously/generously refered patient X to me to treat her..."

Objective Structured Clinical Examination

Today I took the first of many examinations involving standardized patients. It's called the OSCE, but to call it anything more than a checkpoint that 99.9% of med students pass with flying colors is giving it more credit than it deserves.

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Here's how it goes at the best medical school in the country:

You arrive at a floor of an old hospital and stand around and wait for a few minutes with a bunch of other medical school students that are just as nervous as you are even though you all know there is nothing to be afraid of.

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You have some idea that this is going to be a pretty straightforward case ("my elbow hurts"), but the med students who just finished joke that they "never expected that the patient was going to be playing the part of a deranged psychopath," as they walk past.

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Next your herded like cattle into a room where you are given some basic instructions, but all the while the proctor is talking, students are frantically scribbling notes of all the questions that they want to ask while they are in the room--only to find out that you had a few minutes to write after the instructor finishes talking.

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Overhead you hear a mechanical sounding voice say, "Three minutes remaining! Three minutes!" Which is a warning to the students who are currently interviewing patients in rooms 1-10.

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All the while I'm thinking to myself, "What if I seize up in there and forget to do things in the right order, or I ask all of the questions in too mechanical of a way." Or, "What if my patient is a total jerk like the guy that I had to interview during one of our small group practice sessions."

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Then time was called, all of the medical students in the waiting room exit and find the room to which they are assigned (mine was room 5).

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As I'm standing there, my mind is going a million miles a minute. "Should I knock, or shouldn't I--or I could just see what everyone else does--but what if no one knocks and we were supposed to."

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Everyone knocked, so I did. Then I walked into the room and handed the grader (there is a patient and a grader in the room) a sticker with my name on it--from then on you are expected to completely ignore the grader.

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Here's a synopsis of how the interview went (I lucked out and got a really nice patient):

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Me: Hi Mrs. Samples, I'm a medical student at Wayne State--What brings you in today?

Mrs. Samples: Well I've been having this stomach pain for the past few days.

Me: When did it start, what makes it better or worse, how severe is the pain, what kind of pain etc. (waiting in between questions for her to answer)

Mrs S.: 2weeks ago, worse with spicy foods, 5-6, burning

Me (because I knew we were being graded on transitions): So in order to delve a little deeper, I'm going to ask you some questions about your Past Medical History.

(and so on, until I got to social history when I asked her about whether she was sexually active with a partner--which is how they want you to phrase it)

Mrs. S: A PARTNER, I am with my HUSBAND if that's what you mean (she said it jokingly, but her volume took me aback)!

Me: I see. (mumbles something else)

(next up was alcohol--I thought that we were supposed to ask specific questions if someone said they drank anything at all)

Me: So Mrs. S do you drink at all? Alcohol, that is.

Mrs. S: Well I like to have a couple of imported beers every few weekends.

Me: Have you ever felt like you should cut back.

Mrs. S: TWO BEERS, have I ever felt like I should CUT BACK from having TWO BEERS a week. No I haven't

Me: (tentatively) Has anyone ever been annoyed by your drinking?

Mrs. S: ANNOYED BECAUSE I HAD TWO BEERS!?

Me: (not getting that I probably don't have to ask these questions) So I take it you've never felt Guilty about your drinking or had an Eye opener?

Mrs. S: NEVER

Me: Okay, I think it's time we take your blood pressure (which I think I got a little low, by then I just wanted to get out of here--I finished in 12 minutes but most everyone else took less time)

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Then we were sent off to a room to write a SOAP note before we were free to leave. One of my friends had a doctor in the room who asked him if there was "anything else he wanted to ask about the patients past medical history," which worried him because he thought he had already asked all of the questions. I'm just glad I got a trained grader instead of a doctor.

Locus Motivatius

Recently scientists have discovered a new region of the brain found in primates and higher species that has been named the locus motivatius.

Functional MRI studies have shown that this area at intersection of the occipital, temporal and parietal lobes is chronically underdeveloped in the interlopers, the malcontents and the miscreants of the world. But perhaps more interesting is the transient loss of function recently seen by researchers in the United States.

Recently, it has been demonstrated that accute, short term lesions of the locus motivatius are a common occurence around the months of April and May in students of all ages. Symptoms include: lethargy, time wasting, tv watching, and blog posting.

There are no known treatments, but often times symtoms spontaneously resolve with the onset of "warmer weather" or the conclusion of all required classwork for the year.

When Good Anticipation Goes Bad

Played in my first softball game of the season tonight which we won 16-14. Unfortunately all of the planning and anticipation in the world couldn't help me this game. Anticipation without execution was worthless, and I made a couple of errors in the field--fun night though. It's good to be playing on a team.

Here's what I looked like:

Baseball

Very few people appreciate baseball. Most people think that it is just a bunch of standing around swinging a bat as hard as you can. But there is so much to baseball that Joe Smith Fan doesn't even notice.

Baseball is about moving a step to the left because you know that the batter likes to pull the ball. Baseball is stealing on an 0-2 count because the pitcher is likely to throw a breaking ball.


I'll admit it, 99% of baseball is anticipation, and I understand that anticipation isn't that interesting to watch.

But for those who have the willpower to struggle through learning how to hit an unpredictably-moving ball the payoff is enormous. Sure it's satisfying to score a basket in basketball, but you could score 40 points in a quarter and still lose. In baseball, I would argue that there is the highest buildup and importance on any single play--on par with a goal scored in soccer.

Perhaps you might even say that the reason there is an ever decreasing number of baseball fans in this country (and children who learn to play it growing up) is because the way our society is being restructured. We want to be entertained now, not 10 minutes from now, this very instant. And heaven forbid, we have 10 minutes during the day where we aren't on the internet (guilty) or listening to our Ipods, or watching TV.

Where has all the time for contemplation gone, where is the anticipation in life anymore. We want instant gratification and nothing else.

Is it any wonder that there is an increasing number of kids who come down with ADD? Rather than teach our children to appreciate simple things such as a family walk through the woods, we sit them down in front of the TV so we can have some peace and quiet.

Bill Bryson the author of books such as A Walk in the Woods, once wrote:

“To an American the whole purpose of living, the one constant confirmation of continued existence, is to cram as much sensual pleasure as possible into one's mouth more or less continually. Gratification, instant and lavish, is a birthright.”

Take the time to appreciate the anticipation of life.

Red Wings

A few Hockeytown brawls and hits before the big Wings-Avs series starts tonight.

Sleep

Sleep. Most people sleep for about 1/3rd of their life, but rarely do people even think about what is going on when we sleep. For most people sleep is just a required part of living--but few people realize that sleep is essential to life.

When I was at the greatest college on earth I had a friend that purposely went without sleep for as long as he could. After about three days, when he could no longer consciously force himself to stay awake (despite any additional caffeine) his body forced him to drift off to sleep--on the floor where he was sitting.

When I was talking to him a few days later he reported that he began to experience hallucinations after staying awake for ~60 hours straight. After about 70 hours without sleep his body overrode his willpower and forced him to enter the sleep cycle. Without this he would have eventually died.

Of all the things that I've learned this year, probably the most interesting is that those who are physically unable to sleep will eventually die, usually within 9 days of the last time they slept. Although, for people who are able to voluntarily stay awake it has been shown that people can go upwards of 11 days without sleep, as described below.

One of the most common causes of death by insomnia is called Familial Fatal Insomnia. An exceedingly rare condition, FFI is an autosomally dominant condition that has been identified in only 28 families worldwide (according to wikipedia). It was first reported in the 1970s in Italy when two women from the same family died from an insomnia-causing disease, but the actual mutation is thought to have occured in an Italian doctor living in the 17th century.

The cause FFI is somewhat similar to diseases such as variant Crutzfeld-Jacob disease or Kuru inasmuch as it is a disease that results in a buildup of misfolded proteins in the brain (prions). In FFI, a mutation in the genetic code causes the improper translation of genetic material to proteins which causes the protein to improperly fold and aggregate with other misfolded proteins. In FFI, these proteins collect in the sleep regulating region of the thalamus, causing insomnia.

Once the first symptoms appear (usually when the patient is in their 50s), patients have around 7-36 months to live. There is a definitive course of progression for those with FFI.

First patients experience panic attacks, then hallucinations, then weight loss and insomnia, and subsequently dementia and death. At the end of its course, FFI causes patients to forever be stuck in a semi-sleep state which appears much like sleepwalking to observers. Any attempt at drug therapy such as sleeping pills only resulted in a faster spiral into dementia and death.

Equally interesting is the study of forced total sleep deprivation and its affects. In 1964, a 17 year old named Randy Gardner stayed awake for a record-12 days. What follows is the account from wikipedia.

"It is often claimed that Gardner's experiment demonstrated that extreme sleep deprivation has little effect, other than the mood changes associated with tiredness (mood swings, short temper, loss of concentration).[5] This is primarily due to a report by researcher William Dement, who stated that on the tenth day of the experiment, Gardner had been, among other things, able to beat Dement at pinball.

However, Lt. Cmdr. John J. Ross who monitored his health reported serious cognitive and behavioral changes. These included moodiness, problems with concentration and short term memory, paranoia, and hallucinations. On the fourth day he had a delusion that he was Paul Lowe winning the Rose Bowl, and that a street sign was a person. On the eleventh day, when he was asked to subtract seven repeatedly, starting with 100, he stopped at 65. When asked why he had stopped, he replied that he had forgotten what he was doing.[6]

On his final day without sleep, Gardner presided over a press conference where he spoke without slurring or stumbling his words and in general appeared to be in excellent health. "I wanted to prove that bad things didn't happen if you went without sleep," said Gardner. "I thought, 'I can break that (Peter Tripp's 1959) record and I don't think it would be a negative experience."

Getting Along

For those not familiar with The Screwtape Letters (as I was not until I read it recently), CS Lewis wrote The Screwtape Letters from the perspective of the a demon writing to his nephew.

“When two humans have lived together for many years it usually happens that each has tones of voice and expressions...that are almost unendurably irritating to the other. Work on that. Bring fully into the consciousness of your patient (the human that is targeted) that particular lift of his mother’s eyebrows that he learned to dislike in the nursery. Let him assume that she knows how annoying It is and does it to annoy - if you know your job he will not notice the immense improbability of this assumption. And never let him suspect that he has tones and looks which similarly annoy her.”

-C.S. Lewis The Screwtape Letters

Many medical blogs that I have read seem to be filled with primarily angry criticism leveled at the health care system or patients.

And it's easy to do. Although I tried to write my last post as rationally, and un-emotionally as possible, I'm sure there was a bit of frustration throughout it.

So why are there so many angry people in healthcare? I would argue that it is undeniable that were working in an imperfect system. For everything that is wrong with the US health care system, the poorest person in the states receives health care 100 times better than many of the poor throughout the world. So how do we try to we form a productive critique of something, be it health care or otherwise.

I think that part of it is fighting the constant battle against complaint for complaint's sake. I think that it's important to think through whether what you are doing serves any positive purpose or whether it's merely blowing off steam (which isn't to say that there may not be a place for venting--but one should consider if complaints are always best aired amongst other doctors or medical students).

CS Lewis, the British writer who penned the Chronicles of Narnia series, seems to masterfully capture a nuance of our daily living. When we are faced with the same thing day after day, it is human nature to find things to dislike about it. This holds true in relationships ("She always clogs the toilet and leaves me to fix it...") and I think it also is true of medicine.

Just by the by working in close proximity with the same individuals, I think we can find (and perhaps sometimes invent) things to dislike. Medical school has taught me more than medicine, it's taught me to complain. "This is crazy that we are paying X number of dollars when Ph.D student are getting paid 1200 a month."

"I can't believe the questions they asked on that test."

"Professor X has no idea what he is doing."

And the funny thing is, who really cares? The truth is, I'm as guilty as the next person, and that type of complaining does nothing.

When I began medical school I had some idea that life in medicine wasn't going to be a breeze. Although I was a bit wet-behind-the-ears I knew that relying on being a doctor to bring me 100% of my happiness was not realistic. But is this overwhelming flood of complaint part of the problem behind why so many medical students finish their 4th year with little or no hope of enjoying the rest of their professional lives.

Pragmatic, thought-out criticism is vital to continually trying to refine the health care system that many of us will be working in, but I think it's important that we all try to cut out a healthy chunk of the pointless whining we take part in, especially myself.

Is There a Doctor in the House?

Recently I read something about the new program that has begun in nursing where a nurse practicioner has the opportunity to become a doctor.

What? A nurse who is also a doctor? How could this be?

I'll tell you. Nurse Practicioners in some areas now have the opportunity to pursue a degree known as a Doctor of Nurse Practicioning.

Maybe some of you are thinking: This is great! Another possible option for nurses to pursue. No longer are they forced to adhere to the constraints of what it means to be a traditional nurse, e.g. being involved in every aspect of patient care.

I'm not of that opinion. And here's why:

Here's a blurb from the University of Tennesse, Memphis:

"The DNP curriculum is Web-mediated including opportunities for synchronous and asynchronous learning. Students are only required to be on campus 4 times a year (July, December, January, & April) for 5 to 7 days each session. With faculty approval, clinical courses can be completed in the student's state of residence."

What is this, the University of Phoenix? Other reports I've heard have stated that nurses need only complete 1000 hours in order to complete the program. It's absolutely ridiculous on a number of fronts.

First, the amount of experience that a medical doctor gets is at least ten-fold higher the experience that a DNP candidate would have to gain.

Second, what does it mean to be a nurse anyway. What is so wrong about being called a nurse. Personally I think that nursing is one of the most selfless, noble professions that one can pursue. Why is it suddenly necessary that we need nurses proscribing medications and being addressed as doctors.

Third, there was such a righteous fervor over the inventer of the artificial heart (Jarvik) who is a Ph.D "doctor" that was supporting a certain medication on the internet. Where is the fervor now. We're going to see a day where someone with 1000 hours of experience is seeing a patient that has no idea about the difference between a DNP and an MD "doctor." It's disgusting, and I think the biggest reason is because the current doctors of America couldn't care less.

Where were the doctors when malpractice lawsuits have got out of control? Where were doctors when people saw the subtle signs that medicine in the US was going downhill? Where are the doctors now when an exer increasing number of "physician extenders" encroach on what it means to be a doctor? Sadly, the pay is still good, the hours aren't terrible--so the majority of doctors could care less what state the health care system is in when it is handed off to the next generation.

Instead they'd rather complain about duty-hour restrictions, and how medical student today "just aren't as driven as they used to be."

Edmund Burke once said, "The only thing necessary for the triumph [of evil] is for good men to do nothing."

Is what is going on in the medical system evil? I don't think so. But the only thing necessary for it to continue in its downhill trend is for enough of today's doctors to do nothing.

The debate over the validity of having Doctors of Nurse Practicion is sadly going to become a debate over whether the still male dominated doctors are just trying to keep the female dominated nurses down. And at its root I think many people will view it as a gender equality issue. But it isn't. The question is not whether a nurse could be as knowledgeable/valuable as an MD doctor, because I can tell you right now, there are some nurses that are smarter/more adept than some doctors. The question is what would be best for patients

The root of the question is this: What does it mean to be a doctor, and what does it mean to be a nurse? Are there roles that a doctor should fill that a someone trained as a nurse shouldn't be filling? In the same token, are there roles that are better filled by a nurse? I think that the answer to the last two questions are both yes. But if the DNP program (among others) continues, we'll continue to dilute the respect that the average person has for someone who is known as a "doctor" until we're all just "health professionals," despite our vastly different training.

4/48/04 Update: Today in class we had a family of acondroplastic dwarfs come and speak to our class as part of a genetics patient panel. Here is a phrase that the father used, I'll try to reproduce it verbatim.

"When we were at this conference in Dearborn one of the nurse practicioners / doctors got up to tell everyone a story..."

The person he was referencing turned out to be a nurse practicioner and not a doctor. I don't for one second think that John Smith patient has any idea what the difference between a nurse practicioner and a doctor is, and I think they would know even less about what the difference between someone who has NP-C and MD on their coat (if they even looked).

It's misleading to patients and those who keep pushing to expand the role of nurses are exploiting it.

Shadowing

The past two days I have been shadowing a family practice doctor per the requirements of the medical school for completion of the first year, and I was struck with a number of things.

1. I'd like to think of myself as a pretty good communicator, and I don't mean that in a self-aggrandizing kind of way--just ask my fiancee, I'm not always the best at remembering things--but there is something of an art form to medicine. The doctor that I was shadowing absolutely has it down. He know's the "character" that he needs to play during the medical interview process. At times he pretends to be the aloof, almost clown-like character to put people at ease or to get a laugh.

But he also knows that there are times when he has to play the role of counselor, or father, or disciplinarian. There is so much more that goes into medicine than words and formats: he never strictly follows OPQRSTAA (Onset, Provocative/Palliative etc.) when talking about a condition, but he does have his own schpeel that he gives to parents of children under the age of one, e.g. "I like to remind parents to use a lot of sunscreen even if the baby is going to be under an umbrella..."

Moreover, you realize that there are a lot of patients who come in, that he could probably diagnose in a matter of seconds, but still he takes about 5 minutes to talk to the patient about their concerns. For instance, one of the patients who came in clearly was describing a simple pulled muscle, but he still took about 10mins to talk to her about it, before he even began to examine her. Part of it was a desire to rule anything out, but part of it was making sure that the patient felt like she was being heard by someone who cared to listen.

2. The Power of Human Touch. I've heard this a few times throughout medical school but it's important for doctors to touch their patients. Sadly, in this day and age, the first thing that many people would think if you said that was, "Doctor's touching their patients--there should be less of that." Perhaps because of the stigma of the few doctors who touch their patients innappropriately or perhaps due to our Politically Correct/lawsuit happy culture, I fear many doctors may keep their patients at arms length--which is truly sad.

Many patients that come off the streets may have been physically abused or mistreated for their whole lives, and the chance to touch someone in a loving way--e.g. rest one's hand on their shoulder, or even hold the stethescope so that one's fingers rest on their back--is often lost.

3. There's so much pain in this world. One of the women who came into the office had been put on large doses of inhaled steroids to treat a very bad asthma attack that she had had. Her face was the slightest bit edematous and perhaps a bit moon shaped (as is common with high glucocorticoids). And a few minutes into their discussion she said, "My face is so fat...I feel like a freak." And she began to cry. My heart just broke for her.

Maybe because I could empathize or maybe because it is just human nature, but I couldn't help but well up with emotion for her. I wonder if you need to remember how to respond to the patient, while not letting it affect you. Or maybe you just let it affect you and move on, I don't know.

More to come