Limits

Those of you that have read my previous communion meditation have heard me talk about limits. The stark reality of critical illness causes these limits to be displayed most prominently. There is no denying your limits when the patient worsens in front of you and you have no answers. It is undeniable.

The idea that we don't have limits in all other aspects of medicine is pervasive, however, and ridiculous. People are like that, though. We will always deny what we can't do until it becomes immediately obvious that we can't do it. Happens in all other aspects of life. Politics, business, all the same. "Sure, I can get that order done by tomorrow." "Read my lips, no new taxes." We've all heard it. We've all fallen for it, and yet medicine still gets away with it.

There are very practical implications to refusing to acknowledge our shortcomings as a profession. Our stubborness translates into real dollars and cents, real resources wasted in the delusional pursuit of ends that we claim to be able to reach yet lack the tools to reach them. 

End of life is the most obvious case study of this. What do you do if someone is dying but you view death as failure and merely a manifestation of some other lesser physician's previous mistakes? You burn through resources, that's what. You throw the kitchen sink at the "problem." And then? The patient dies. Every time. Without exception. 

It's an oversimplification of course. Some folks are critically ill and will recover wonderfully. We can't perfectly predict who will recover and who won't, but we certainly have a good idea sometimes. More importantly, and more central to what I want to say today, we often know who wants to use those resources and who doesn't.

Informed consent was initiated in the noble pursuit of joint decision making and patient autonomy. Why don't we tell the patient all the possibilities and let them decide? Sounds nice. It's imperfect, though. How do I adequately explain the risks and benefits of a procedure that it took years of school and training to master and understand? Explain that in ten minutes? Forget about it. Its a farce.

No matter how many forms you get patients to sign saying they understand everything and have made the decision all by themselves, physicians will always play a central role in making patients' medical decisions. Sadly, this is where physicians' refusal to acknowledge our limits most hampers, and dare I say harms, our patients. What do you do if a patient is wavering on a procedure that could prolong their life if you believe that death is failure and only happens if you allow it to happen? You push. You cajole. You tell them how they really want the procedure, how it will help them.

Patients will relent usually. They trust their physicians. However, they won't be better for it. Unlike physicians and their God complex, most of the patients that I have cared for do not view death as failure. They view death for what it is. Inevitable. If we are really acting as a medical fiduciary for our patients, then how should this affect our decision making? Should we make decisions based on our personal views of death or our patients?

If we accept that our patients views of death and disease are more important than our own, then this begins to have every day implications. Do you use low value tests and procedures that often result in much lower quality of life with minute quantity of life gain? Probably not. Out the window goes "routine" blood tests every three months, a lot of heart caths and CT scans. Costs come down. Patients receive care more in line with what we know works the best.

From an individual physician standpoint, the trade off comes in time. It will take serious time to explain to patients why they don't need a test. Much more time than to simply order the tests. As in all situations, inaction must be explained more than action, even when inaction is the correct action. That means a lot more of our day sitting in exam rooms simply talking to patients, learning their views and preferences. We must know the whole person if we are to consider the whole person in our decision making.

That should be no problem, though. Most physicians indicate that they got into medicine for the purpose of knowing and helping people. So spending large amounts of time talking to patients and not ordering tests that can make you more money should be second nature, right? Let's hope so...

Cough, Colds, and Chaos Saturday

There are a lot of big match-ups in college football today. HumorMD Jr. is a bit upset about the timing of all of them. The four games that he wants to watch are all scheduled within an hour of each other. What can I say major network producers? I'm not mad, just disappointed (cue maternal shake of the head). Regardless of the poor planning, tonight could either clarify the national championship race or set off an atomic bomb in the college football world. I'm hoping for the latter.

Here in our house, Chaos Saturday has a whole different meaning. HumorMD Jr. is right on the border between bottle sizes. We tried out the bigger one today, and his eyes were a bit bigger than his stomach. Overall he did well, but he did manage to give Dad a formula shower a few times. Not a big deal as far as I'm concerned. I've already written about the showers that the other end of his gastrointestinal tract can produce. I'll take this end any day of the week.

On the medical front, I've been doing some work for Yahoo recently. There have been many coughs and colds coming into the clinic with the weather getting cooler. To that end, I wrote up some educational material on antibiotics and sore throats that you can find here. For those that have been struck by a viral pharyngitis, here are a few things to try for symptomatic relief:

• honey tea
• salt gargles
• Halls lozenges
• Chloraseptic spray
• Mucinex (if you have a lot of junk running down your throat)
• Fluids

That is the list I usually give out to my patients. Nothing is a magic bullet, but it should help some. Time is your best friend. Try not to scream at the TV when your team loses tonight as well. Nothing like a little laryngeal irritation to go with your pharyngitis!

Article Concerning the Rules for Organizing and kNowing how to Name Your clinical study Magically, or the ACRONYM article

Most scientific disciplines, at their very core, amount to a bunch of big five year olds getting together and seeing if they can make something fun happen. Trial and error is the name of the game, and medicine is no different. We call our grand experiments clinical trials. One group of patients gets the newest idea for treatment, and the other group gets either nothing or the old treatment. The race is on, and we see who wins (vast oversimplification, but the general idea is there). Those of you in the audience that are medical know much more than this of course. However, there is a little known secret to clinical trials that, in my estimation, is essential to the results of a clinical trial having a lasting impact on medicine...the name.

If you ever been involved in a medical argument, you will hear the names of clinical trials flying left and right like bullets in warfare. Conjecture and personal opinion will only get you so far. We treat based on facts, people, and we get our facts from trials. You might think that we physicians are too objective to be swayed by things like the name of the clinical trial...you'd be wrong. It's a lot easier to quote the FAME or COURAGE trial than some long sentence that actually says what the trial is investigating. Heck, even the lowly med student or resident can remember a one word name or catchy phrase. Just that much easier to whip out that latest trial during rounds and impress the attending. For those that don't know, spontaneously producing a clinical trial on the spot during rounds to either prove your point or prove someone else wrong is the holy grail of medical students. You pull this off, and you can write your ticket for that rotation. It's kind of like winning American Idol without the fuss of months of singing on national television and listening to judges make dumb comments.

You may wonder what kind of criteria there are for a "memorable" clinical trial name. Based on previous results, here are a few guidelines (not strict of course, as creativity is encouraged here):

1. Brevity is key. One word is better than two. Shorter is better...you get the picture.

2. References to mythology are not only acceptable, but encouraged. Remember your audience. We're nerds.

3. The more bold and glamorous, the better. Titles like AFFIRM, AWESOME, VICTORY are examples. Go big or go home. Picture how the title will be listed when you are accepting the Nobel...and then make it even more bold.

4. The acronym doesn't have to fit perfectly, or at all. The original idea was the one word allows you to remember the entire name of the trial. Now that the fad has taken off, investigators no longer feel the need to confined by things like the definition of the word acronym. Just name it what you want and figure out the rest later.

5. A catchy name with a medical play on words is just flat awesome. My favorite example would have to be PROVE IT-TIMI 22. The number at the end aside, this title is genius. For the non medical folk, TIMI stands for Thrombolysis in Myocardial Infarction. The name can be found everywhere now. There is a TIMI risk score, TIMI study group, etc. Other clinical trials from the same study group have the TIMI acronym, but none achieved what this one did. A good title that plays directly off the name of your study group? Please. Stop it. We're not worthy.

So there you go folks. I've given you the keys to the academic kingdom. Go forth, publish, and change the world. For you laypeople, this should give you reassurance that medicine follows fads just like normal culture does. We ain't any better; we just dress it up enough to make it sound good.

The Doctor Becomes the Patient

Like many doctors, part of what inspired me to go into medicine was spending a considerable amount of time on the wrong side of the doctor-patient relationship (that being the patient of course). Before medical school, that would make me a normal patient. Once you get some medical training, the term normal patient never applies to you. Ask anyone in the medical field. Doctors are the worst patients. Very few can handle such a drastic role change. One day you are making life or death decisions (OK, slightly exaggerated) on sick patients and the next you're asking the nurse if you can "use the potty." Quite the role reversal there. I've seen physicians-turned-patient argue with nursing staff about how they gave daily stool softeners 15 minutes too early. We really are a crazy bunch.

I've taken care of many of these patients before, and the key is let them make decisions. I'm not talking about letting them treat themselves but giving options whenever possible. They will be much more likely to go along with you if they feel that they're participating in their own care. Being given multiple options for how and where to urinate may seem trivial, but it may be what holds together the psyche of some of the most neurotic people you will ever meet (I know, I'm one of them). The fun part is that the patient usually knows exactly what you are doing. They have likely treated other patients like this themselves. You can usually share a good laugh with them once you get their initial anxiety under control. Good physicians are fairly self aware. Part of what makes them good is the ability to perfect every detail of what they do. That includes being able to "poo poo in the potty."

In other news, life is busy at the HumorMD household. We have recently had a new addition, which we are very proud of. HumorMD Jr. and I had some quality time last night. We discussed diagnosing a STEMI (type of heart attack), and he's already an expert. Maybe we'll add world renowned physician to his previously mentioned athletic prowess. I just feel bad for the other kids getting compared to him...

4 AM

In light of my recent post outlining my thoughts on the "work above all else" culture of medicine, I thought I would take you through the stages of a typical call night. Given the new work hour rules, this could mean different things to different people. What I will describe is the traditional 30 hour call that has long been a part of medical training (now 28 hour call for 2nd and 3rd year residents).

The morning of your call day is spent just like every other day. You pre round and then round formally on all your team's patients. If you are the intern, you will likely actually pay attention during all of rounds that day. On the traditional medicine team, each intern is responsible for half the team with the upper level resident overseeing everyone. You can imagine that it is not uncommon as an intern to enter a transcendental state where your body remains still but your mind is 2 continents away when you arrive at a patient's room that is not yours. A call day changes this because after everyone leaves that evening, you will be managing the patient through the night. Best to actually have some idea of what is going on if the nurses are going to page you when a patient starts circling the drain.

Next phase is lunch and then getting work done in the afternoon. Again, this is not much different than ordinary except you are likely to start admitting new patients. If your team is high functioning and generally humane, the non call members of the team will take the first few admits since you have to stay all night. If you have made enemies amongst your team or work with people looking to make you their enemy, then its time to pony up and take your punishment. Trying to admit new patients while discharging others and getting all your other work done is not fun, but we have all done it. Having a really rough afternoon in this regard can mean one of two things. You have either already exhausted the sick population around your hospital, or it is the tip of the iceberg that is about to sink your ship.

This brings us to the night portion of your call. For new interns, this is the part known as "I'm so scared I crapped my pants." For the rest, this is "another night stuck in this stupid place." You will know if that precious commodity known as sleep will be enjoyed by midnight. Still working at midnight equals no sleep. Caught up by midnight equals possible to catch a few hours. This rule of midnight is based on my experience and is nearly flawless.

Next up on your schedule is the dreaded hour known as 4 AM. This is rock bottom if the rule of midnight has stated that you are still awake and working. Though tired at other portions of your 30 (so sorry, 28) hour call, this is where you will feel physically and mentally beat down to the max. Personally, 4 AM is usually associated with a wave of nausea, inability to sit more than one minute without my eyelids drooping, and deep desire to end anyone's life that stands between me and the closest bed. This is where the men are separated from the boys. Many a med student's career has crashed and burned at 4 AM as they have totally lost it and submitted to the weariness. I've had multiple med students downright refuse to do work at this hour. Some have even just gone home without even asking, never to show up again. There is nothing glamorous about making it through this phase of the guantlet. There is only survival.

If indeed you do have the mental fortitude to survive, then the hour of 5AM is when the glow of hope appears on the horizon. With only one hour until everyone else arrives, you can now begin to effortlessly push away work with the time old adage of "I think that decision is best made by the primary team." Nurses know this phrase well. They also know that all decisions except for those that are emergent will be pushed off until 6AM once that phrase appears and the hospital grinds to a screeching halt. For the resident, it is now time to grab whatever catnap possible, round on your patients, and get the heck out of there. One more 4 AM between you and freedom (aka the end of residency) is now gone.