Posts tagged centerpiece

Why Physicians Need to Write

I would argue that one cannot be a good doctor without being able to communicate one’s thoughts, knowledge, opinions, and analyses in writing.

I write for many reasons. One of them is to reflect on my day, to debrief on the moments that my colleagues and seniors impart on me. Another reason I continue to write is to keep the passion of medicine alive.

It is no secret that most of us lose our ability to empathize in third year, a year where we are exposed to the real world of medicine for the first time. We are young and impressionable and bad habits can quickly form if one is not careful. Our passion for medicine, as it turns out, is a fragile and easily corruptible entity; I try not to lose sight of that.

I write for these two reasons and many more personal ones as well. Why do you write?

Tailored Presentations. Dr. Cranquis made a comment about presenting a patient to various specialties. I briefly touched on this subject in Need-to-know Basis but I think it is worth revisiting in full. Every doctor would like a summary of information, but your delivery of it cannot be a one-size-fits-all package. A good case presentation requires delivering the information that is pertinent to the specialty and “selling” or driving the attending to the diagnosis you have in mind. Here are some quick pointers that I go by.  Identifier: A good presentation begins with a short summary of who the patient is. This includes things like age, gender, ethnicity, and functional status (independent, bed bound, institutionalized etc.). Other pertinent points included here may be if the patient has been generally healthy or has multiple co-morbidities. Finally, if a patient comes in with a condition that is associated with risk factors, you can list them here if they apply. “This is a 56 year old independent caucasian man with a history of hypertension, dyslipidemia, smoking, and obesity who presents with shortness of breath on exertion and retrosternal pain.” Beyond this basic structure, a hospital specialist will require additional information along with the focused problem when you present the case. An obstetrician will want to have the patient’s gravida status, blood type, and screening status up front; a neurologist will want to also know the handedness of a patient and the baseline neurological status; a surgeon just wants to know what the problem was and the diagnosis. The clinical years become an exercise in learning these differences. This is of course all well and good when you are presenting to your attending. However, once you need to consult someone, be it the specialist or the ER, keeping the presentations clear and succinct becomes key. No one has time to listen to a fifteen minute presentation over the phone. The first step is to make your intentions clear. This usually happens either before you present your patient or once you have given them an idea of who they are dealing with.  “This is a 40 year old man previously healthy man with no past psychiatric illness, currently experiencing significant personal and financial stressors who was found by police after ingesting unknown quantity of tylenols within the last four hours. He is currently stable and being treated per protocol and we are waiting for the next liver panel. We are consulting psychiatry ahead of time for suicidal ideation and risk assessment.”  The next step, following what has already been described above is to discuss the pertinent points of the history. This includes the identifiers but also the patient’s condition and what has been done or course in hospital that is relevant to the case.  Sometimes that little snippet of information is enough. Sometimes they may require more so always keep everything within arms reach and present information as they require them. Maybe they do have time to listen to a full presentation, perhaps only a few snippets. If you can keep your audience and the issues in mind - identifier, specialty tailored points, reason for consultation, pertinent history and current plans of action - you will be able to deliver a well formed presentation every time. Next pearl: ?…Previous pearl: And Stuff Like That…

Tailored Presentations.

Dr. Cranquis made a comment about presenting a patient to various specialties. I briefly touched on this subject in Need-to-know Basis but I think it is worth revisiting in full.

Every doctor would like a summary of information, but your delivery of it cannot be a one-size-fits-all package. A good case presentation requires delivering the information that is pertinent to the specialty and “selling” or driving the attending to the diagnosis you have in mind. Here are some quick pointers that I go by. 

Identifier: A good presentation begins with a short summary of who the patient is. This includes things like age, gender, ethnicity, and functional status (independent, bed bound, institutionalized etc.). Other pertinent points included here may be if the patient has been generally healthy or has multiple co-morbidities. Finally, if a patient comes in with a condition that is associated with risk factors, you can list them here if they apply.

“This is a 56 year old independent caucasian man with a history of hypertension, dyslipidemia, smoking, and obesity who presents with shortness of breath on exertion and retrosternal pain.”

Beyond this basic structure, a hospital specialist will require additional information along with the focused problem when you present the case. An obstetrician will want to have the patient’s gravida status, blood type, and screening status up front; a neurologist will want to also know the handedness of a patient and the baseline neurological status; a surgeon just wants to know what the problem was and the diagnosis. The clinical years become an exercise in learning these differences.

This is of course all well and good when you are presenting to your attending. However, once you need to consult someone, be it the specialist or the ER, keeping the presentations clear and succinct becomes key. No one has time to listen to a fifteen minute presentation over the phone.

The first step is to make your intentions clear. This usually happens either before you present your patient or once you have given them an idea of who they are dealing with. 

“This is a 40 year old man previously healthy man with no past psychiatric illness, currently experiencing significant personal and financial stressors who was found by police after ingesting unknown quantity of tylenols within the last four hours. He is currently stable and being treated per protocol and we are waiting for the next liver panel. We are consulting psychiatry ahead of time for suicidal ideation and risk assessment.” 

The next step, following what has already been described above is to discuss the pertinent points of the history. This includes the identifiers but also the patient’s condition and what has been done or course in hospital that is relevant to the case. 

Sometimes that little snippet of information is enough. Sometimes they may require more so always keep everything within arms reach and present information as they require them. Maybe they do have time to listen to a full presentation, perhaps only a few snippets.

If you can keep your audience and the issues in mind - identifier, specialty tailored points, reason for consultation, pertinent history and current plans of action - you will be able to deliver a well formed presentation every time.

Next pearl: ?…
Previous pearl: And Stuff Like That…

A Rookie Cut

Over the past year, I have noticed a young man attending the barbershop I frequent. A tall and well-dressed adolescent who bared some resemblance to my barber, he initially started off with the scut work: sweeping the floor, greeting the customers, and watching. Always watching intently as my barber trimmed my hair.

Slowly, over time, he had begun to learn the tools of the trade - the different scissors and the brushes; the straight razor and the strop - and began to practice on the dummy heads.

Today, I went to the barbershop to find him cutting what must be his first set of heads full of hair. All the while, he was receiving pointers and tips from my barber, his father.

His eyes were focused, his body was tense, as he trimmed the weight from the man’s temple. Snip. Snip. As the locks fell to the floor, he re-examined his work. Was it too little? Was it too much?

“Remember to angle your brush up. It’ll give you more room to work with,” his father would say, and he would oblige and try again, with more angling of his left wrist. In the end, the older man seemed satisfied with the young man’s work. A sizeable tip came the trainee’s way, to which he hurriedly returned to the man.

“The cut is free. I’m still practicing.”

“You’re always going to be practicing. Besides, you’ve earned it. Keep the change.” The customer gathered himself and took his cane as he thanked the barber in training yet again. The young man was pleased.

“Next?” Of all the people waiting in the barbershop, no one took a second glance.

“Does your son know what he’s doing? I mean it’s a rookie cut,” came one snappy customer. No one moved. They wanted the expert, the experienced barber, the man who knew every bump under every patch of hair on their heads. They wanted his father. The brilliance of the man’s eyes that a moment ago seemed so alive, dulled. He put down the gown and reached for the broom.

“Sure, I’ll go,” I said, taking up his offer. He gave me a smile and motioned me to the chair. “Have a seat.”

I understood his plight. We were all in the same boat together. As learners, we depend on the good will of the people we see for us to gain experience, to be better, to become professionals. The process must start somewhere. It was time I returned this favour to another student.

“Caesar trim. Sides short. Front long,” his father called out.

“Hey.”

“Hello.”

“Thanks for giving me the opportunity.”

“No problem. We all have to start somewhere.”

Death surrounds us. Recently, I have had many emotionally exhaustive shifts at the hospital. Some of my patients looked well; others did not. Regardless, many of them have died under my team’s care. We are all destined to that outcome one way or another. In that sense, perhaps it was meant to be - the diseases had progressed too far or the patient could not carry the burden any longer. But my mind lingers on the life that escaped with their last breath, on the last dying days where my life had become intertwined with theirs. My mind races and wanders to what could have been. Had we done enough? Did I do something wrong? If I had seen them a few hours earlier, could I have found a sign of the impending end? Could I have then given the patient and their family a few more precious moments together?  Despite my meticulous combing of the chart, I could never find the answers to these questions. We had done everything we could. In the hospital, death surrounds us, ever hovering in the air, lurking behind every chest pain, kidney failure, and fever. Though we make advances everyday, Death always gets the last word.  “I’m sorry we could not do more,” I once said to a rapidly deteriorating patient. “It’s alright. I know you guys tried. I’m grateful for everything. We gave it a hell of a run, didn’t we?” He mustered his fading energy to form a smile. “Yeah, you sure did.” We shook hands for one last time. “I’m ready.”

Death surrounds us.

Recently, I have had many emotionally exhaustive shifts at the hospital. Some of my patients looked well; others did not. Regardless, many of them have died under my team’s care.

We are all destined to that outcome one way or another. In that sense, perhaps it was meant to be - the diseases had progressed too far or the patient could not carry the burden any longer. But my mind lingers on the life that escaped with their last breath, on the last dying days where my life had become intertwined with theirs.

My mind races and wanders to what could have been. Had we done enough? Did I do something wrong? If I had seen them a few hours earlier, could I have found a sign of the impending end? Could I have then given the patient and their family a few more precious moments together? 

Despite my meticulous combing of the chart, I could never find the answers to these questions. We had done everything we could.

In the hospital, death surrounds us, ever hovering in the air, lurking behind every chest pain, kidney failure, and fever. Though we make advances everyday, Death always gets the last word. 

“I’m sorry we could not do more,” I once said to a rapidly deteriorating patient.

“It’s alright. I know you guys tried. I’m grateful for everything. We gave it a hell of a run, didn’t we?” He mustered his fading energy to form a smile.

“Yeah, you sure did.” We shook hands for one last time.

“I’m ready.”

And Stuff Like That. Previously, I spoke about summarizing information and conveying efficient data in writing. This time, I would like to talk about conveying efficient information in words.  Our day-to-day conversations are often filled with extraneous words, interjections, and flourishes that add very little to the content. As an exercise, just listen to some of your friends or family members as they talk. Actively listen to how you speak. What words could you have removed and still get your point across? “This patient did not have any fevers or chills and stuff like that,” is an example. “Um, the patient looked a little short of breath and maybe a little sweaty, you know?” is another. Take a moment and think about what you want to say and how you want to say it. Get to the heart of the matter without embellishing facts. A good place to start practicing is in your daily conversations. On the ward, dictating is a practice that forces you to be conscientious of your word choice. Regardless, it takes time, patience, and insight to break the habit. Eventually, you can present information to your colleagues and attendings succinctly, clearly, and professionally. This patient had no fever or chills. He was mildly short of breath and diaphoretic. Next Pearl: Tailored Presentations…Previous Pearl: Impression…

And Stuff Like That.

Previously, I spoke about summarizing information and conveying efficient data in writing. This time, I would like to talk about conveying efficient information in words. 

Our day-to-day conversations are often filled with extraneous words, interjections, and flourishes that add very little to the content. As an exercise, just listen to some of your friends or family members as they talk. Actively listen to how you speak. What words could you have removed and still get your point across?

“This patient did not have any fevers or chills and stuff like that,” is an example. “Um, the patient looked a little short of breath and maybe a little sweaty, you know?” is another.

Take a moment and think about what you want to say and how you want to say it. Get to the heart of the matter without embellishing facts. A good place to start practicing is in your daily conversations. On the ward, dictating is a practice that forces you to be conscientious of your word choice. Regardless, it takes time, patience, and insight to break the habit.

Eventually, you can present information to your colleagues and attendings succinctly, clearly, and professionally.

This patient had no fever or chills. He was mildly short of breath and diaphoretic.


Next Pearl: Tailored Presentations…
Previous Pearl: Impression…

Becoming a Mentor

“Hello,” came a quiet voice. I glanced up from my paperwork to find a young lady leaning in across the counter. Her wavy brown hair framed a shy smile. A white coat hardened her otherwise soft and subdued attire while the red tubing and metal instrument around her neck helped identify her.

“Hello. How are you?”

“I am good. How are you?”

“Not too bad. Can I help you with something?

“Yes. I am a second year medical student. I was sent up here for our clinical skills session to assess a patient and I was hoping, if you have time, to help me with a few points on my presentation.”

I stopped for a moment, unsure of myself. Could I help this student? Perhaps I am not the right one to ask. But what is the harm in trying?

Read more »

The Zebra

“Tom, come take a look at this,” the attending beckons excitedly. I get up from the charting station and walk over to his computer.

A CT scan fills his screen with a very large, obvious abnormality. “This is one of the biggest I have seen in my career,” he says. The patient had developed not only a large mass but a rare one, causing all sorts of systemic anomalies. Given the extent, it would be inoperable.

As we proceed to the patient’s room, the doctor explains the clinical presentation of mass effect on the body. His eyes are wide and flicker with a fiery excitement. He can barely control the rate of his words as he gushes about the various pieces of the unique clinical puzzle in front of him.

“Are you excited?” he asks after he finishes. I reply that it is “interesting,” much to his displeasure. “How could you not be excited? You might not see this ever again in your life.”

But all I could think about was how this mass, this zebra on a CT scan would soon bring our patient to their untimely death.

Within, I watched the attending as he spoke to the patient and their family about the situation. He explained things with such professionalism, clarity and assurance that I could see no better way it could have gone.

Yet it continued to disturb me, his excitement in it all.

Joseph Addison, a poet said: “Everything that is new or uncommon raises a pleasure in the imagination, because it fills the soul with an agreeable surprise, gratifies its curiosity, and gives it an idea of which it was not before possessed.”

For my attending, who may have seen thousands upon thousands of patients with very similar presentations, this zebra case must have stirred up a renewed sense of adventure, a break from an otherwise regular routine of patients.

Perhaps, it is that hot flush of novelty, that infectious high of our peers that perpetuate our own behaviour.

Too often our fascinations show outwardly as our primary intent. In the process, we forget that the patient has a name, has a right to be treated with dignity, has an illness that still needs to be treated. In the process, we forget that the condition does not define the patient any more than he defines the condition.

It is a strange situation we find ourselves in, to be excited and captivated by our morbid curiosity; on some level, we must in order to learn and improve as clinicians; at the end of the day however, it must come at the expense of someone else’s health. For that, I must always consider the fine line that separates respectful and disrespectful learning.

“Pretty neat findings, eh?” He nudges me. I take a look back at the patient’s room. I watch as the family huddle in an emotional embrace as they come to terms with our news.

“Yeah. It is really interesting,” I mutter bleakly.

Impression. Once I have gathered all of the information from a patient, presenting it is always easier. I can list off the history and physical as I would a bullet pointed list. What is always more of a struggle is formulating my impression and plan. No one ever taught me how to write or present an appropriate impression. This is the part of any report that summarizes the findings and presents reasons for or against different diagnoses and the issues at hand. This is what I do. Begin with a one or two sentence summary identifying the patient, including history that is relevant to the chief complaint. Then, proceed to address the problems. When tackling a patient’s problems, begin by considering them in three ways: Predisposing factors: What aspects of the patient’s presentation put them at increased risk of their chief complaint. For example, in a patient who comes in with an acute COPD exacerbation, it is important to preface your impression with identifying the patient as a heavy smoker. Precipitating factors: What are the events or reasons the patient’s chief complaint presented. For example, an intoxicated patient who is coming in with multi-system trauma secondary to a motor vehicle accident, the precipitating factor is prior alcoholic consumption. Perpetuating factors: What aspects of the patient’s presentation places them at risk of repeat incidence. A patient with type I diabetes who is noncompliant to insulin can put them at risk for diabetic ketoacidosis. Present the issues along with these factors as appropriate and then dive into a differential, starting with the most likely/working diagnosis first. Be able to list some reasons why a diagnosis is on the differential list, the findings that are favourable or unfavourable to it, even if it is only to rule out fatal conditions that could passably be related. Next pearl: And Stuff Like That…Previous pearl: Efficient Data…

Impression.

Once I have gathered all of the information from a patient, presenting it is always easier. I can list off the history and physical as I would a bullet pointed list. What is always more of a struggle is formulating my impression and plan.

No one ever taught me how to write or present an appropriate impression. This is the part of any report that summarizes the findings and presents reasons for or against different diagnoses and the issues at hand. This is what I do.

Begin with a one or two sentence summary identifying the patient, including history that is relevant to the chief complaint. Then, proceed to address the problems.

When tackling a patient’s problems, begin by considering them in three ways:

  • Predisposing factors: What aspects of the patient’s presentation put them at increased risk of their chief complaint. For example, in a patient who comes in with an acute COPD exacerbation, it is important to preface your impression with identifying the patient as a heavy smoker.
  • Precipitating factors: What are the events or reasons the patient’s chief complaint presented. For example, an intoxicated patient who is coming in with multi-system trauma secondary to a motor vehicle accident, the precipitating factor is prior alcoholic consumption.
  • Perpetuating factors: What aspects of the patient’s presentation places them at risk of repeat incidence. A patient with type I diabetes who is noncompliant to insulin can put them at risk for diabetic ketoacidosis.

Present the issues along with these factors as appropriate and then dive into a differential, starting with the most likely/working diagnosis first. Be able to list some reasons why a diagnosis is on the differential list, the findings that are favourable or unfavourable to it, even if it is only to rule out fatal conditions that could passably be related.

Next pearl: And Stuff Like That…
Previous pearl: Efficient Data…

Describe a Situation. Applying to medical school is a year long process. It requires a lot of forward thinking and planning. Applying to residencies is no different. I am at that point now that making preparations for fourth year electives and planning for residency options becomes important. One of the big hurdles of applying to residencies is the interview process. This is an opportunity for different program directors and residents to see how I willinteract with them, with situations. One of the most often asked questions goes along the lines of: “Describe a situation where…” In the clerkship years, make it a habit to take note of very specific situations that you can think back on for a future interview scenario. Remind yourself of that time you demonstrated integrity, or that other occasion where you saw how errors were made. You can write them down on a little notepad, or you can even send yourself an email on your phone for future reference. Over time, you will have accummulated a small catalogue of situations that will aid you in a future interview process. Next pearl: Efficient Data…Previous pearl: Moments of Zen…

Describe a Situation.

Applying to medical school is a year long process. It requires a lot of forward thinking and planning. Applying to residencies is no different. I am at that point now that making preparations for fourth year electives and planning for residency options becomes important.

One of the big hurdles of applying to residencies is the interview process. This is an opportunity for different program directors and residents to see how I willinteract with them, with situations. One of the most often asked questions goes along the lines of:

“Describe a situation where…”

In the clerkship years, make it a habit to take note of very specific situations that you can think back on for a future interview scenario. Remind yourself of that time you demonstrated integrity, or that other occasion where you saw how errors were made. You can write them down on a little notepad, or you can even send yourself an email on your phone for future reference. Over time, you will have accummulated a small catalogue of situations that will aid you in a future interview process.

Next pearl: Efficient Data…
Previous pearl: Moments of Zen…

The Surgery Oral Examination Summarized

After weeks of studying, it had come down to this day: the surgery oral examination. Historically, it has remained one of the most challenging exams in third year. It covers a wide variety of subspecialties to great depth; of course, who can forget the intimidation factor of a face to face interrogation?

I went into the first station, sheer terror gripping tight my heart with icy fingers, knowing full well what merciless horrors senior students had suffered in this hour in years past. I hoped I was up to the job.

I was not prepared for what I was about to endure.

From the moment I was seated and the timer started, the questions lay siege. An unrelenting torrent that had me choking and drowning in my own words. The surgeons meticulously picked apart my answers and showed me how wrong some of my answers were.

It was a sorry sight indeed; the other stations were no better.

I felt embarrassed, shamed and defeated. I had not only come face to face with the expectations of the surgeon and fell well short, but I had come face to face with my own. Worse than the biting comments of a surgeon was knowing that I had let myself down.

Having said that, the entire exam took me to that space that is often talked about but not always explored: the space of the unknown. The surgeons today forced me inwards and ripped from the depths of my mind the large voids in my knowledge. And though the experience getting there was not a pleasant one, I must move past this and press onward with the hope that I can retrace my steps to this sacred place in my knowledge scape and rebuild.