Pronounced my first patient just now. The hospice unit called down to our team room, so my resident and I put on our white coats, buttoned them up to look presentable, and headed upstairs.

Luckily there was no family in the room–I’m sure it would have been much more uncomfortable if there had been. Felt the patient: warm; checked for a pulse: none; saw no reaction of the pupils to light. It was very strange, putting a stethoscope to a warm, lifeless chest wall. You’re so used to hearing the rhythmic whooshing of the breath sounds or the lub-dub of the heart that it’s a little un-nerving when there’s nothing there. I moved my stethoscope to a few other places– wait, did I hear something? –but there was simply nothing there.

After a quick confirmation by the resident, we turned turned around to the nurse, looking at the clock on the wall. “Okay, we’ll call it Eight Thirty-Seven. Thanks.”

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Started my Medicine Sub-I today; anyone have advice for the sub-intern (or intern, for that matter)? Tips and tricks appreciated.

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Oh lordy is this a terrible idea.

Google and Microsoft are trying to put patients in charge of their medical data , and there’s even some screenshots of the Google Health online application . I love you, Google, and my friends that work for you, but are you honestly this naive about people’s level of health knowledge ? Roni Zeiger, primary care doc turned Google Health employee, what are you thinking ?

Patients without medical training but that actually understand all the nuances of their diseases and medications, I applaud you; most of your fellow patients, however, don’t. I strongly advocate for patients to read and learn as much as they can about their diseases and drugs they take, but this is not the way to go about it.

I’ll start by bitching, and then offer some constructive suggestions.

What the hell, Google/Microsoft:

1. This is supposed to be a medical record , right? For use by physicians , right? Because from the looks of it, you want patients to use medical terminology (which most don’t know, use, or understand) to create their medical record. You want people to know terms like “AV Nodal Re-Entrant Tachycardia” or “Partial Complex Seizure secondary to Temporal Lobe Neoplasm” or “Takayashu’s Thyroiditis,” right? Because that’s what I’m expecting to see in a medical record. Often I don’t hear these terms from patients. I hear that they have, in order, “a funny heart rhythm,” “seizures,” and “thyroid problems.” If the medical record was just for public display, like a web photo gallery or a Facebook profile, “funny heart rhythm” would be fine. But I actually use the medical record to diagnose and treat patients, and “funny heart rhythm” doesn’t cut it.
2. Are we supposed to trust this medical record? Now, I know as physicians we’re not supposed to trust anything we don’t see with our own eyes or done by our own lab or radiology department, but at least in a medical record controlled by a medical team, it’s a health care professional that’s putting information in there, so it’s a little more reliable (but far from perfect, doctors are incorrect too). I see patients that say they don’t have high blood pressure even though they do, and their medical record shows they’re persistently hypertensive in clinic; I see patients that claim they have “high sugars” or “pre-diabetes” when they don’t; I know people who read something online making them think they have symptoms of disease X and just decide that they probably have it. I also see patients with multiple allergies, which aren’t true “allergies” but just “adverse reactions.” The two are very different and have very serious differences.
3. Should I rely on this data in my management of my patients? Some of these medical records will be great, others will be okay, others will be terrible. How do I know which medical records of which patients to trust? Should we rank patients on their health literacy? What happens if your Google Medical Record lists your blood type as A-, and I give you AB+ blood?
4. What’s the point of the medical record if it doesn’t provide me with accurate and up to date data? There are subtleties to labs and reports and studies and findings that don’t often get reported to patients, because at the time they aren’t significant or important. (Note: I try to explain as much as I can to patients, but often it’s easier to explain basics.) For example, if a patient has certain changes on an EKG, it can indicate subtle signs of a heart attack–but if they’re also on an older EKG, you worry much less about a heart attack. I don’t want to see something in a chart that just says “EKG normal on 8/8/2007,” I want need to know more. Also, what if a patient forgets to update their medical record for several years, and has lots of problems in the interim? (Now I fully realize that today’s medical records often miss a lot of medical information and are often incomplete, but if people are proposing major changes to medical records, we should probably think a bit harder about this than just lurching forward.)
5. What if the patient leaves out medical information he or she is embarrassed or ashamed of? I need to know if you use drugs, or if you have sex with multiple partners, or if you have HIV, or if you’ve had STDs in the past, for example. (Yes, yes, I know, if it’s important, I’m still going to ask about it again, but in the current medical record, if we know about it and it’s relevant, we’re likely to know about it up front in the chart, because the chart hopefully contains relevant, important data, not just the data that’s not uncomfortable to discuss.)

(I know I’m going to piss off a lot of people with this post, but I’m truly not trying to be condescending. I know a lot of patients understand more about their diseases than their physicians, and many are very empowered and active. This is fantastic, but the vast majority of patients are not to this level, and I worry about a system which assumes that patients are active to this level, and even have any interest in managing their medical record. Add to this the fact that even growing up in a medical household, I didn’t really understand many medical conditions–and didn’t even understand them as a pre-clinical medical student, either.)

Let’s work this out, Google/Microsoft:

1. I would love you to be a national medical record. I would love for patients to be able to enter basic information about themsevles and then allow their doctors and hospitals to write notes in them and upload data to them. A central repository for EKGs, Xrays, CT scans, Echos, with full reports would be absolutely revolutionary. Absolutely. There’d probably be reactions from patients who read their doctors’ notes and don’t like the way they’re described “Obese gentleman in no apparent distress” or “Patient denies smoking” (as if we’re accusing the patient), but a system where I could see what other doctors saw would be hugely helpful. We get patients transfered from Nevada and Southern California routinely and often have very little information about what happened to them at other hospitals. Scary, huh?
2. Help us fix HIPAA. It’s kind of funny–since Google nor Microsoft are health care providers or payers, they don’t have to conform to HIPAA online privacy standards. Physicians, however, have tons of online standards we have to use to access online health information. (Now the question stands, if physicians access these online medical records, will they have to then conform to HIPAA privacy standards?) Please–make it easier to safely protect people’s information online–doctors want it to be less confusing and safer, just like patients.
3. I’m all for patients learning about their diseases, and facilitating this is great–but let there be a distinction between patient-entered information and physician-entered information. Or allow patients to add comments or extra information to what doctors say.

Those are starting points. I’d love to hear what other patients and health care providers think. As is now the case, comments are open, but keep it civil–constructively criticize my arrogance if you want. I fully admit that I have a doctor-skewed perspective, and I’d like to be educated about things I’m missing because of it. (Please also note that the people that are online that read health blogs are likely pretty highly educated or have health interests, so your own experience is likely not representative of the patients we normally see.)

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As residency application season rapidly approaches, I’ve gotten into similar conversations with many friends about why they’re choosing a particular specialty, and one particular theme keeps coming out:

In subspecialty outpatient clinics, there’s more time to spend with patients: visits are usually scheduled as 30 minutes long.

In a world where we’re trained in primary care clinics at the pace that our attendings can keep up with (15 minutes per visit) and we’re feeling completely overwhelmed by trying to address the patient’s hypertension, diabetes, hyperlipidemia, peripheral neuropathy, prior MI, stroke, and liver disease (not to mention learning all the drugs and dosages), of course we like the specialties where we have more time to figure out all our patients problems.

(I’d also argue that we got into medicine to help patients, not just cure their diseases–and that medical students, just like residents and attendings, prefer to have the time to get to know our patients as people, not just as the guy with poorly controlled diabetes with hemoglobin A1C’s in the 10-12 range.)

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A bunch of people bit my head off on my A Better Way To Round post, assuming that I was ignoring patient communication. Idiot Savant’s comment pretty much sums it up–the point I was making was that because we spend so much needless time rounding, we often lack time for patients, in terms of communicating properly, frequently, and promptly, updating them and them families, doing procedures, etc.

I want to improve rounding so that we medical students, interns, residents, fellows, and attendings have more time for more important stuff than collecting numbers from a computer screen and copying them down multiple times. (Each person in the above list spends at the very, very least one hour doing this. Every. Day.)

Other ideas for improving patient care and communication:

• A little notebook and pen for every inpatient. They write down their questions, and when we stop by we answer them. Easy.
• For the less acute patients who are needing to reach some goal before discharge (I’m particularly thinking about fluid-retaining CHF patients who need to diurese but go to the cafeteria way too often): A calendar where they can list their daily weights, to motivate them. This could be applied to other patient populations as well.

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Dr. Centor summarizes a bunch of internists talking about the current state of residents and thoughts on work hours , but in my perspective leaves a number of things out:

• No offense to the old school, but medicine today is a lot more complex than it was even 10 years ago. I’m not saying that residency was any easier, but there’s simply much more knowledge, information, data, treatments, diagnoses, studies, and procedures that we have today than we did previously. And residents (and medical students) are expected to know them all. Granted we have better technologies to make us more efficient (12 lead EKGs with rhythm strips and telemetry and not having to use suction cups, and computers that spit out lab values, and electronic medical records and digital imaging), but medical school is still 4 years long, and most residency programs haven’t changed in length, either. In the same amount of training time, we’re pimped on which genes are involved in which diseases, expected to keep up with all the new data and trials that are constantly being published, as well as know how to appropriately use new medications, titrate them, and anticipate their possible side effects. We have to be able to do basic reads of CT scans and other imaging. It is a lot to learn. (And at the same time, we can now sustain patients and keep them alive longer, and there’s all the ethical issues that now come along with that as well.)
• Let’s say my generation does want a better balance of personal and professional life. (Just hypothesizing for now.) Can you blame us? We’re working just as hard as you old schoolers did in medical school and residency, but our average debt is so much higher ! Many of us have also grown up (not me, fortunately) with parents and families who developed their professional lives at the expense of their personal and family lives, and it ended in divorce, frustration, or unhappiness–and we don’t want to repeat the mistake ourselves. And honestly, do you want an unhappy, jaded physician treating you, anyway? (Medical students are on average older now than they used to be, which also leaves fewer years to have a family or develop relationships.)
• The 80-hour work week, just like everything else, has its pros and cons–no doubt about it. But who would you want writing your orders, if you came into the ER with chest pain. The groggy resident who’s running on empty, who might just forget the heparin, or might miss subtle ST depressions or elevations?
• Or perhaps we’re just an egotistical, self-centered generation who require praise at every turn and who care more about our own happiness than our patients’ lives. (If you’ve met any of my classmates and seen their accomplishments or how they talk about their patients, I’d find this hard to believe.) But why else might our supposed “work ethic” have changed? Could it be the change in the practice of medicine? From an art and a practice to a business? From calling the preson you’re treating “your patient” to “your consumer” or “your client?” From focusing on what’s best for the patient to what’s best “medico-legally” as well?

Just some random opinions, devils’ advocacies, and thoughts.

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Shadowfax’s hilarious and freaking bizarre story of a guy seeing Christmas elves reminds me of a patient 2 months ago who, when asked if he knew why he was in the hospital, answered, “I’m here for a meat inspection.” He told this to multiple people.

And my roommate’s girlfriend had a patient who, when asked the date, would frequently answer “6007” for the year.

So, what’s your weirdest chief complaint/response to orientation question? (Comments are open!)

(Update, I take that back, my best one-liner was in the ER awhile back. The chief complaint, which I’m sure the triage nurse got a kick out of writing–since she’d normally just write “altered mental status” was “911 called by roommate, patient was meeowing like a cat in his room.)

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Or: Why Lab Results And/Or Your Doctor Is Frustrating You

I find a good number of patients don’t really understand how doctors make decisions about diagnosis and treatment, so I thought I’d try to explain it all out. Here we go.

We’ll start with background knowledge and information. All the information that we learn before we start seeing patients as medical students is there to build a foundation to try to guide our thinking. For example, we take anatomy to understand the body and the relationship of everything to everything else, so that we can start to think about what might be causing someone’s problem. (For example, if you have pain in your abdomen just below the lower ribs on your right side — we call that the “right upper quadrant” or “RUQ” — it leads us to think of things in that area that might be hurting. Not just your liver or gall bladder, but sometimes pneumonias in the bottom of the right lung, the stomach, or the small intestine.) Sometimes the body can trick us, so we have to make sure we aren’t guided solely by anatomy, but it gives us a place to start. (This trickiness is called “referred pain;” if your diaphragm hurts, it can actually cause shoulder pain; if your gall bladder hurts, it can actually cause shoulder blade pain. Curse you, confusing body!)

And that’s just anatomy. We learn physiology, which tells us the rules the body follows to keep itself alive; pathophysiology, which tells us what happens when the body messes up, but still tries to apply those body rules; pharmacology, which tells us how drugs work on cells and organs in our bodies, which drugs to use to treat certain diseases, and the predicted side effects of those drugs.

Like I said, this is all just foundation. As we say, “Patients don’t read the textbooks,” meaning that when someone comes in with a certain type of problem, they don’t always show the same symptoms or problems we learned about initially. Guidance but not absolute prediction. (The “classic” picture of someone having a heart attack is severe chest pressure, clutching their chest with their arm. But very often, people don’t have chest pressure–they may just feel weak, or have difficulty breathing.)

Now one of the hardest parts of medical school is inverting your knowledge. See, when we learn in the classroom for the first two years of school, it’s learning about diseases . But you patients don’t come to us with diseases, you come to us with symptoms . And the damned thing about symptoms is that there’s any number of body systems or diseases or problems that can cause your symptom. Only very rarely does one single symptom let a doctor immediately know the disease. (And of course we have to know the disease accurately to know the treatment, because some treatments can make certain diseases worse if we’re wrong.)

Here’s an example. Let’s take difficulty breathing, or “shortness of breath” or “SOB” as we call it. Here’s a very short list of the causes, based on body system (the real list is much much longer):

• Vascular Causes: Aortic Dissection
• Infection: Pneumonia
• Neoplasm: Lung Cancer
• Drugs: Amiodarone-Induced Pulmonary Fibrosis
• Idiopathic Causes: Sarcoidosis
• Congenital Causes: Heart Defect
• Autoimmune Causes: Lupus
• Trauma Causes: Pneumothorax; Toxin Causes: Aspirin Ingestion
• Endocrine/Metabolic Causes: Diabetes (Diabetic Ketoacidosis)

… and so on. So when you see a doctor for a certain problem you’re having, we try to tease together parts of your story, and add in your other symptoms, what we know about your other medical problems, what medications you’re taking, your age, your life, and your risk factors for certain diseases to come up with a list of things that we think it might be. It’s all educated guesses. This list that we put together is called a “differential diagnosis,” and it’s ranked in order of likelihood. The minute you start talking to your doctor, he or she has started putting together a differential diagnosis. And as you say certain things, or answer certain questions, that differential can immediately change. Heart attack can go from top of the list to somewhere near the bottom, with heart burn replacing it at the top.

By this point, just with talking to a patient and examining him or her, many common diseases can often be diagnosed, based just on this information. But our top guess on our “differential” isn’t always right. So even if we’re pretty sure it’s, say, hepatitis, it still could be other things. (This is all going on inside our heads while we’re talking to you, hence us sometimes seeming like we’re zoning out or not listening to you.)

Since we believe in “Above all do no harm,” and we generally try to only do things (give medications, recommend procedures or surgeries) if we believe that the benefits outweigh the risks ( everything has a risk and a benefit, including seemingly harmless over-the-counter medications), sometimes we need a test to let us confirm that our diagnosis is correct. If you have a classic story and exam pointing toward strep throat, the doctor may just go ahead and prescribe antibiotics. But if the story isn’t exactly right, or the timing is off, or your throat doesn’t totally look like strep, the doctor may order a strep test to confirm that he or she is right.

And that’s just the beginning. (To be continued…)

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My attending on anti-coagulation in the hospital (okay, I’m paraphrasing):

“I think anti-coagulation is one of the most frustrating and unrewarding parts of medicine, because you never see the positive outcomes, you only see the strokes when you don’t anti-coagulate, or the bleeds when you do.”

Agreed.

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Of course, my Op-Ed opinion piece for the local NPR station got trumped by another piece on the exact same topic, Health Literacy. Never mind them, I’ll just publish it myself. Enjoy. (Click on the play button to… play.) Or just read along.

[audio:http://www.grahamazon.com/etc/HealthLiteracy.mp3]

I visited an elementary school last week to answer some students’ health questions, and it was fantastic. I was thrilled to see them engaged and learning about their health and bodies–because I have a number of patients who know nothing about their diseases or medications.

Being a medical student gives me a magic power: the ability to instantly recognize my patients’ eyes glazing over, confused or unsure about what a doctor is saying. Doctors these days are under immense time pressure, and often don’t even realize when patients are lost. I’m something of a quasi-doctor: I understand the basics of diagnosis and treatment from the medical side, but I’m still able to take a patient’s perspective and realize when something may be over his or her head.

Part of this poor communication comes from “doctor-talk,” the language that we speak to each other, with such wonderful terms as “diaphoretic” (that just means “sweaty”). (Part of my job as a medical student is to learn the doctor-talk so I can communicate accurately and effectively. It’s *not* to make patients feel stupid or small, although I know it often has that effect.)

Sometimes we forget to switch back into English for our patients. Other times patient confusion is due to cultural factors, poor translation, or a lack of understanding about the body or disease. And even if doctors *do* try to make sure patients understand, guilt or embarrassment make some patients nod their heads anyway.

A major component of this confusion is “health literacy.” People who are not health literate have problems understanding pill bottle instructions or side effects, or even realizing why diseases like diabetes or hypertension are important to control. There are almost 90 million adults in the US who have only limited health literacy skills–that’s more than 4 in 10.

We often see the consequences of health illiteracy in the ER–my future specialty. I may diagnose a patient with a kidney infection, only to find out antibiotics were already prescribed by another ER, but the patient simply isn’t taking them. The communication of “You must take these to get better” got lost somewhere along the line, for any number of reasons. An extra 30 seconds of explanation can often save a patient a lot of pain, an ER visit… and many health care dollars.

We often refer to “futile care” as the exhorbitant costs of sustaining a dying patient, but we clearly deliver “futile care” to young, healthy patients all the time, too–it’s effort just as wasted if the patient doesn’t understand what he or she needs to do to get better (or not get worse). Why diagnose and treat patients if they don’t understand the treatment plan? A magic cancer pill is useless if the patient doesn’t understand how, when, and why to take it correctly. As physicians, we must do better.

But we need your help as patients, too, because we’re in a time-crunched world with lots of sick patients with many problems. Here’s what you can do:

1) Ask questions if you don’t understand something.
2) Write your questions down so they’re efficient to answer.

These are simple solutions, and will help us all in the long run.

In fact, I propose a new health care button for doctors’ white coats, right next to the “Ask me if I’ve washed my hands” one. How about: “Ask me… what the heck I’m saying.”

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