Monday, August 28, 2017

only time will tell


As a physician, and at times as a patient, I enjoy the advantage of knowing, before I see a doctor, what questions he will (or should) ask concerning the reason for my visit. This saves time and effort because he doesn’t have to tease out the diagnostic clues that are part of the “history of the present illness.” I hand them to him in perfect order.
“It is much more important
to know what sort of patient
has a disease
than what sort of disease
a patient has.”
~William Osler~
Likewise, I already know what the physical exam should include and how it should be performed. I can predict what tests he will order, and he doesn’t have to go into detail about the treatment he is recommending. I know what he is going to say before he says a word.
Unfortunately, this means I pick right up on it when my own physician slacks off. When he fails to ask the right questions. When he neglects parts of the physical examination. When he fails to follow-up on X-ray findings or blood tests.
This is how mistakes are made…and I know why it happens. Not because he lacks expertise in his field. Not because he is uncaring. Not because he is lazy or unmotivated. (I know him better than that…).
No, there are other forces at work. He is seeing a patient every 10-15 minutes, so he is usually running behind schedule. The history and physical exam must focus solely on what he suspects is wrong. There simply isn’t time to be as thorough as he would like to be.
“It’s not about having enough time.
It’s about making enough time.”
~Racheal Bermingham~
Perhaps he's falling behind on his “productivity quotient” and risks losing his job if he doesn’t pick up the pace.
Or maybe the EMR he is using doesn’t have a bullet for the information he wants to include, so it goes unrecorded.
All the health care mandates and initiatives in the world will not solve the problem of TIME. Time spent with the patient. Time to reflect on his illness. Time to help him heal.
Now is the time for change.
“Lack of time
is actually
lack of priorities.”
~Tim Ferriss~

Monday, August 14, 2017

true story


True story:
A friend of mine has been in terrible pain for over a year. She has orthopedic problems and degenerative disc disease in her back resulting in unrelenting sciatica. She also has a rare autoimmune disorder that requires her to be on chronic steroid treatment. Her initial workup, several years ago, found nothing operable so she has been taking substantial doses of opiates daily since then in a futile effort to control her pain. She can’t drive. She can barely make it up the stairs to her bedroom. She is experiencing a deepening depression because of it.

“You can avoid reality
but you can’t avoid the consequences
of avoiding reality.”
~Ann Rand~
Why hasn’t she gone back for re-evaluation?
Because, as she puts it, “They’ll think I’m a whiner.” She doesn’t want to take up the doctor’s precious time when other patients are worse off. She doesn’t have the language to describe her pain…not the nature of it, not the severity of it, not the timing of it. She tells herself she’s a sissy, that other people wouldn’t complain about it so she shouldn’t, either. She is convinced the doctor won’t find anything wrong and he’ll laugh her out of the office, or worse, he’ll assume she’s seeking drugs. Or, worse yet, he’ll decide she needs surgery after all, and she definitely doesn’t want that.
Her situation illustrates some of the obstacles patients encounter when trying to tell their story--the chief complaint and the history of the present illness.
What happens in situations like this is that the patient lies. He minimizes the severity of his symptoms because he doesn’t want to sound like a complainer or weakling. He may be embarrassed to admit that he can’t keep up with things anymore because he’s afraid he’ll lose his job. Even if he suspects the gravity of the problem, he may be reluctant to learn the truth. For example, the patient with chest discomfort may describe it as indigestion or heartburn in an attempt to dissuade the doctor who is sure he has CAD.
“You’d be surprised
what lengths people will go to
not to face what’s real and painful inside them.”
These are some of the obstacles that serve to confound the patient’s narrative: denial, shame, fear, ignorance, and dread.
To make a long story short, at my insistence my friend scheduled an appointment to see her pain management specialist. I’ll be going with her that day because, as a physician, I know what she's up against. As a writer, I think I can help her tell her story.
“One day I will find the right words
and they will be simple.”
~Jack Kerouac~






Sunday, August 6, 2017

when storytelling is a life-saving skill

The art of storytelling is as old as the spoken word. It’s an important part of every culture, race and religion. It entertains, informs, and connects mankind across time and space.

Most people enjoy reading or listening to stories at their leisure. The health care provider, on the other hand, listens to stories all day long because it’s part of his job. The first thing he does when he sits down with a patient is to elicit the history, or story, of the patient’s illness. It forms the basis of all that follows: performing the physical examination, arriving at a diagnosis, and formulating a treatment plan for the patient.

The health care provider listens for specific details that help him make the diagnosis. If the patient’s problem is pain, the provider needs to know where the patient feels it, whether it’s sharp or dull, steady or throbbing, constant or intermittent. He needs to know how long the patient has had the pain—for a day? For a week? For years? What makes it worse? What makes it better? For example, the pain associated with a migraine headache is throbbing whereas in a tension headache it is usually steady. Gallbladder pain can come and go for months whereas the patient with appendicitis has steady pain and usually seeks medical care within a day or two. These are important details.

The problem is that patients don’t know what the physician needs to hear. They don’t arrive at the office with a list of relevant signs and symptoms. It’s the provider’s job to ask about them, but he has only so much time to get to the bottom of the patient’s problem.

For this reason, doctors often redirect the patient who appears to be getting off-track or is slow coming up with answers. In fact, one frequently quoted study found that most physicians interrupt and redirect the patient when they are as few as 18 seconds into the interview. Frequent redirection leads the patient to believe that what he wants to say isn’t important or relevant. Instead, he tries to give the doctor the information he needs while other parts of the story go untold.
Let’s say the patient presents with a three day history of abdominal pain. He answers all of his doctor’s questions. The pain has been present for four days. It started in his upper abdomen, but now it is diffuse. The pain is constant and it radiates into his back. Eating makes it worse. In fact, the patient says he hasn’t been able to keep anything down for the past two days. After a focused physical exam, and after running a few tests, the physician correctly diagnoses him with acute pancreatitis. But that doesn’t explain why the patient starts to complain of a headache, has trouble keeping his balance and appears confused twenty-four hours after being admitted to the hospital.

What the doctor doesn’t know is that the patient has been drinking heavily because his wife walked out on him recently. In fact, he blacked out a couple of days ago and he woke up on the floor next to the bed. The patient didn’t mention it because he was busy answering the doctor’s questions about his stomach ache. So the doctor missed the small subdural bleed the patient sustained during the fall until days later when he finally developed symptoms.

This is a theoretical scenario but it highlights an important problem. Obtaining an accurate and complete medical history takes time. When the patient is constantly redirected in order to satisfy the provider’s agenda, important parts of the story may be left out.

This reinforces the importance of the patient’s narrative in medicine. It isn’t just “nice” to know the whole story. Besides being a sign of respect and concern, the ability to listen to the patient can be a life-saving skill.
"You treat a disease:
you win, you lose.
You treat a person:
I guarantee you win--
no matter what the outcome."
~Patch Adams~