A good stepwise process, for future reference in residency, from a lecture today in Family Medicine. This applies to both deaths and bad news in terms of studies, lab results, etc. (It’s also often a good idea to have the social worker or chaplain with you if you can.)

1. Make a setting. Don’t do it in a hallway, go find a private, quiet place to sit and talk.
2. Introduce yourself. Often the family has seen a number of different people caring for their loved one–doctors, nurses, techs, etc–so reiterate who you are, especially to the significant other.
3. Ask what they know already. It gives you a sense of their knowledge level, what they might be expecting, what they’re worried about, so you don’t repeat anything or speak above or below their level of understanding and medical knowledge.
4. Make a “preperatory statement.” This readies and focuses the loved ones for what they’re about to hear. A good suggestion from the lecturer: Don’t say “I have some bad news.” Try, “I have something very important I need to tell you right now.”
5. Deliver the news. Be brief, direct, and succinct, 25 words or less.
6. Pause, wait for a response. Be there and be present.
7. Arrange a follow-up for later. A phone call, a card–it doesn’t have to take extraordinary effort.
8. Take care of yourself. It’s emotionally trying and exhausting to do this, so allow yourself to grieve however you may express that, too.

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In two common infections of the vagina, bacterial vaginosis (and sometimes in trichomonas vaginalis) your doctor may do a “whiff” test, where he or she takes some discharge, drops some potassium hydroxide on it (a base, KOH) and smells it for a fishy, foul odor. The base causes some foul-smelling amines to be released: cadaverine and putrescine . What great names.

Interestingly, some women will complain of foul odor after intercourse, and the reaction is the same: semen is basic, and when it mixes with the discharge, you get the same release of cadaverine and putrescine. Cool.

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Flea (RIP) used to talk about the medicalization of childhood –that kids don’t just run the spectrum of normal variation, that everything nowadays has to be a diagnosis or a pathology that requires treatment. I’ve started to come across the same thing in pregnancy.

There’s this strange phenomenon that several of the docs, nurses, and assistants have commented on–that women will come in, having missed their periods, taken several at-home pregnancy tests, all positive, and still want or need the doctor to “deem them” pregnant. (Plus often a number of the pregnancy changes: nausea, vomitting, breast tenderness, bleeding gums, etc.) Just seems strange that in some ways we’re so out of touch with our bodies–or at least the “natural” changes of them–that we need some “authority on bodies” (doctors) to concur with our own diagnosis.

I guess you can take this a step further and apply it to a lot of common complaints: a weird twitch somewhere, a strange sensation. In some ways it makes sense–you see plenty of patients who wait too long before they see a doctor for what turns out to be a heart attack, or cancer, or stroke, or out of control diabetes–and you wonder how they could possibly have waited so long. And on the other hand, you have people coming in for weird aches and feelings that are just typical, natural weirdness of our bodies.

Sometimes I wonder if a lot of the extremes are due to the break up of the extended family, and the more migratory lives of people. Had a newly-pregnant woman been living with her parents or grandparents, the mothers would just immediately recognize, “Duh, you’re pregnant.” Likewise, the guy who looks green and is clutching is chest might be convinced to seek medical care if his family members urge him to.

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Started Family Medicine this week (my last clerkship!) and very much agree with the philosophy, probably more than the Internal Medicine approach: that you must take the patient in context. That much of what we consider “health” doesn’t fit within the conventional boundaries of medicine, and that a person’s environment greatly affects his or her health. A couple of thoughts from the introductory lectures, one by a patient advocate on Advance (not Advanced!) Directives:

• On the term “life support,” as in: We would have to place your dying father on life support or else he will die tonight: We should call it “artificial organ support,” not life support. Life is something that we define as people–and all “life support” does is keep the organs in the body working longer.
• On making sure everyone has an advance directive: Maybe it’s a bit morbid, but what if on Thanksgiving or some family holiday, everyone brought out papers and wrote an AD? Then everyone in the family would have their wishes known, and there’d be less fighting later.
• Did you know you can write people out of an Advance Directive? Say you have a child who hasn’t been around for a long time, or a trouble-maker in the family–you can specifically mention in your directive that you do not want that person to take part in health care decisions for you. (I hadn’t considered this as a possibility.) ( Some info on ADs. )
• On “Do Not Resuscitate”: In Georgia (and it seems, slowly spreading elsewhere), health care may be switching to the term “Allow Natural Death,” trying to make it known that death is a normal part of life, and that it cannot (and perhaps should not) be fought at any cost.

And finally, via the wonderful Gooznews :

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