Posts tagged medicine

Five Doctors Go Hunting

Five doctors - a general practitioner, a paediatrician, an internist, a surgeon, and a pathologist - decided to take a weekend trip and go duck hunting.

Soon after they were in their duck blind, a bird flew over and the general practitioner said, “I think that is a duck,” and so he took aim and slowly squeezed the trigger…but then he lowered his rifle and said, “I better get a second opinion.” “Back of the line,” said the group.

Another bird flew overhead and the paediatrician said, “I think this one is a duck too,” and he took aim…only to lower his rifle and say “but that duck might be a mother have baby ducks somewhere.” “Back of the line,” said the group.

A third bird flew overhead and the internist shouted, “That looked like a duck, etiologically classified as Animalia, Chordata, Aves, Anseriformes, Anatidae, based on the size, I am judging it to be a male, with an estimated weight of…” Before he could finish his thorough assessment or raise his rifle, the bird was gone. “We do not need to hear all that gibberish. Leave it to me,” said the surgeon.

Then a fourth bird flew overhead and the surgeon immediately raised his rifle and with no hesitation shot the bird out of the sky. He then turned to the pathologist standing next to him and said, “now go find out if that was a duck.”

Tailored Presentations: Replies

  • Thumri: I like this post and think it is true, but from my experience, all of medical education is designed to help us avoid what you describe as the pain and shame of not knowing. I would be interested to know what you think would be a better way to summarize quickly and communicate about complicated patients.
  • ShrinkRants: ...I do wish standard medical practice were different. These tips, and the condensed presentations given as examples, are shot through and through with impersonal “objective” language. Such language hides the subjective nature of its collection. It works directly against any reflection on the discourses that shape what is included and excluded. It is all about knowing. The tips are offered in service of helping presenters look and feel knowledgable and avoid the shame of not knowing. The people the presentations describe are not present as people, as living breathing, hoping, fearing persons. They are reduced to a collection of facts, signs, and symptoms. This is not, cannot in this form be, “patient-centered medicine.” Until we as a profession change our everyday language, we will not be able to practice patient-centered medicine... (Read the rest at http://bit.ly/18M0bDz)
  • The shame of not knowing is pervasive but I would agree that it does not mean that it must remain an engrained part of this culture. There are positive ways of delivering feedback. It really depends on the doctor I work with. While subjectivity is generally excluded from these presentations, it helps bring the pertinent information to the forefront, the pieces that are most easily examined, investigated and followed. I always try my best to paint a picture of the person behind the presentation, to tell a story and not just a list of facts. From more descriptors to using a FIFE model to better understand this patient's subjective state, I try to keep them all intact, even if my audience is not completely interested. But the purpose is always to deliver concise presentation that informs enough for another doctor to draw his own conclusions and to do his job effectively. Having said that, some specialties simply do not lend well to subjective language at all in a presentation.

medicalstate

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…

Trend of Drug Overdoses in the United States. While the interpretation of the data is somewhat imprecise and makes many assumptions and condensations, it is still shows a very concerning trend. Of course, prescribed medications plays a large part of this picture. As my attendings often say: “we, as healthcare providers, are the single largest supplier of medications, appropriately used and abused.”  Most of those within the pharmaceuticals category had unknown intent but a strikingly large number exacted unintentional self-harm. This is from such issues as drug interactions, improper dosing, improper medications et cetera. Death in this portion, perhaps greater than any other category here, is an avoidable outcome. What can we do as a health care system to curb this growing trend in prescribed pharmaceuticals? Is it a simple matter of education and systematic checks or can we do more? Discuss below.

Trend of Drug Overdoses in the United States.

While the interpretation of the data is somewhat imprecise and makes many assumptions and condensations, it is still shows a very concerning trend.

Of course, prescribed medications plays a large part of this picture. As my attendings often say: “we, as healthcare providers, are the single largest supplier of medications, appropriately used and abused.” 

Most of those within the pharmaceuticals category had unknown intent but a strikingly large number exacted unintentional self-harm. This is from such issues as drug interactions, improper dosing, improper medications et cetera. Death in this portion, perhaps greater than any other category here, is an avoidable outcome.

What can we do as a health care system to curb this growing trend in prescribed pharmaceuticals? Is it a simple matter of education and systematic checks or can we do more? Discuss below.

popsci.com

3D Printer Makes World’s Smallest Human ‘Livers.’

3D printing technology just keeps getting better and better. This time, scientists at Organovo in San Diego were able to create a 3D printer that prints using liver cells. Layering these cells into a histologically correct lattice, the team plans to model disease processes and medication effects more accurately.

The plan is to eventually be able to print fully functional human livers that are viable for transplantation.

newscientist.com

I have a board exam in five days and I am freaking out. This is the culmination of my life. If I fail it I will have no job.
A R2 stresses over her upcoming OSCE and board exam.

Pew pew pew! Insert Coin to Play

  • In the designated urology operating room hangs a scoreboard for the urologists' greenlight laser TURP procedure. The laser machine records both the amount of laser energy used for the procedure and the elapsed time as you blast away prostate tissue with the green laser. There could be no better setup for a bunch of avid gamers. Level clear!
  • #1: AAA - 1,214,687 joules
  • #2: AAA - 623,692 joules
  • #3: AAA - 463,921 joules
  • #4: RAS - 452,480 joules
  • #5: SCM - 398,723 joules
Plate 81 from The anatomy of the arteries of the human body, with its applications to pathology and operative surgery by Richard Quain. When I look at this illustration, I am truly impressed with the detail of it all. I also find myself unable to shake the thoughts of compartment syndrome, necrotizing fasciitis, and deep vein thrombosis as I inspect its details, says the medical mind that does not know when to quit.

Plate 81 from The anatomy of the arteries of the human body, with its applications to pathology and operative surgery by Richard Quain.

When I look at this illustration, I am truly impressed with the detail of it all. I also find myself unable to shake the thoughts of compartment syndrome, necrotizing fasciitis, and deep vein thrombosis as I inspect its details, says the medical mind that does not know when to quit.

Finishing Internal Exam Part Two

I thought the exam overall went pretty well. Having only had two oral exams though, this one included, I still find the practice to be very awkward and disjointed.

For example, the examiner goes by a script and does not move to the next section until I have finished my answer and will tell me information afterwards that I may not have requested because it is in the script. Though I had a list of investigations I wanted to have done, the timing of some of them was inappropriate for that particular moment and I was reserving them for - in my mind - a later point in the case as it unfolded. It was a terrible mistake and easy points were lost.

Having said that, I feel that I eventually did come to the right diagnoses for the cases I had, though my process getting there could definitely have been slicker and more thorough.

Lesson learned.

Finishing Internal Exam Part One

Overall it was actually a very straight forward and easy exam. And that just makes it all the more painful when my nerves get the best of me and I miss the easy points.

Square yourself away and get your act together, brain!