Posts tagged patient care
Exam Tomorrow.
Psychiatry has been a very nuanced rotation. We become so used to dealing with the objective and the tangible in our day to day practice that the abstract and intangible aspects of a patient’s health are often lost. However, if we dig deep enough, we often surprise ourselves with how many people struggle with psychiatric issues. It is definitely a weakness of mine and one that I will need to continue to improve in my later weeks in psychiatry.
For the time being, the psychiatry exam will be my focus.
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.
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.
Please Remember Patient Confidentiality.
As a medical student who sees patients through many specialties, I often find myself in situations where a distant conversation catches my ear. Because I identify.
I identify who is being referred…
“This patient of mine is not doing so well. Developed a pulmonary embolism following…”
..or did I? I listen longer. Perhaps I was wrong.
We do our best always to keep the confidence of our information. We find quiet, private areas. We discuss them in hushed voices, hidden from public scrutiny. We remove as many identifiers as is feasible to convey our intentions.
Yet we still let slip on occasion. We are human after all. This sign is a testament to that. It is a reminder that we must all be mindful of our words.
You never know who is listening.
The way I see it, the standards and recommendations of practice change from year to year, decade to decade. What does not change is the art of medicine, the ability to build a relationship with your patients.
If you can take away that from your training, you will do fine. The rest you can look up and read.
He Who Inspires…
Recently, I had the great pleasure of working with a specialist. While I found him to be an excellent doctor and teacher of his field, he impressed me more with his mastery of the art of medicine.
Watching him work reminded me of the heart it takes to work with patients.
After spending a morning with him, I can honestly say without hesitation: I have never been more inspired about medicine.
There was nothing complicated or mysterious about his interactions with patients. There was no parlour tricks or unnatural question structure. It was just him, his patient, and the problem. His language was simple, his examples relevant, and his explanations honest.
We often talk about empathy as a tool to help us connect to a patient. In my hands, it is an embarrassingly clunky, yet unrefined hammer of “it must be frustrating,” or that “I see you are upset.” His was the precision cut scalpel that sliced to the core issues and emotions.
Patients simply opened up to and connected with him. And I, sitting in my seat, even felt the transference of emotions at times as well. It was a powerful and beautiful display of the art of medicine at work.
To his patients, it was an overwhelming sense of feeling human in the eyes of a stranger, to not feel like a bag of meat at the mercy of a probe and a blade. To him, it was just the way medicine had always been and would continue to be.
For me, it was the revelation of what it is to truly practice great medicine.
Not Forgotten
- On the ward.
- Me: ...I am going upstairs, I have to check on another patient but I will come back for the lab results.
- Nurse: Sounds good.
- Patient: Doctor Tom, please wait a moment.
- Me: *Recognizing the patient from a week prior* Mr. Smith, good to see you up and about. Did you ever go for that test? What can I do for you?
- Patient: You remembered my name...
- Me: That I did...what can I do for you, Mr. Smith?
- Patient becomes overcome with emotion.
Old School
As I walked into the office, the strong smell of coffee and alcohol sanitizer wafted in the air. The walls were plastered with dedications and certificates, organized chronologically across its four walls, extending back well into the 1960s. The office was a mess, but that is of course a matter of perspective. To the doctor whom it belonged, it was organized chaos. Though a computer sat in the corner with the EMR humming on the screen, it was clear that this was a doctor who still preferred his paper files.
And the files lay everywhere.
Palliative Care
Last week, I spent a few hours in a palliative care unit.
As medical students, we’re fixated on the living. What drug can cure that symptom. How surgery can remove the cancer. Where we can find a bed so that the patient with diabetes can have her complications managed.
Rationally, we know that everyone dies. We dissect cadavers in our anatomy classes. We read about fatal diseases in our textbooks and see pictures of brain tumours and mangled hearts cut open.
But still, we believe we can save everyone.
A heartfelt reflection from a medical student on the process of palliation and what it means to deliver care in its purest sense.
There comes a day for each and every one of us to have to come to terms with death. In this profession, it is always the looming destination of those we interact with, the final stop. With every effort we make, we buy more time for patients, their lives, and the lives of those whom they have touched. However, the truth is that despite even our best efforts, sometimes life cannot be extended, or it is decided to not be the best course. Ultimately what matters as much or more than the measured outcome of life extension, is the quality of life, life completion, and dying with dignity.
Watson the computer lending itself to cancer research analysis to deliver individualized cancer diagnostic and treatment recommendations, partners with Memorial Sloan-Kettering.
As the whole medical community moves towards patient-centric care, there has been a growing emphasis for personalized or individualized care, care that is delivered not just from a guideline or a standard but tailored to your specific needs. The push for pharmacogenetics is one such example. Now, the physicians at Memorial Sloan-Kettering are tackling the concept of personalized care from a different perspective. How do you stay on top of the large wealth of information and the advances of medical practice?
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