The Art of Medicine

Wednesday, November 09, 2005

Importance of human interaction

There is a misconception that supportive interactions require more staff or more time and are therefore more costly. Although labor costs are a substantial part of any hospital budget, the interactions themselves add nothing to the budget. Kindness is free. Listening to patients or answering their questions costs nothing. It could be argued that negative interactions - alienating patients, being unresponsive to their needs, or limiting their sense of control - can be very costly in lost patient revenues and perhaps litigation. Angry, frustrated, or frightened patients may be combative, withdrawn, and less cooperative, requiring far more time than it would have taken to interact with them initially in a positive way.

- Frampton S, Gilpin L, Charmel P. Putting Patients First. pg 9

This is not taught enough to us in medical school. While we focus much on problem-solving in a clinical sense, we have given little thought to problem-preempting in the social sense. Much of medicine is too little too late, often palliative and complicated by our own mistakes - but unfortunately that is also true of the way we relate to patients.

We could afford to think more about the social/psychological factors involved in the condition, the causation, and possible complications down the road. Only then are we physicians in the true sense of the word - healer, friend and comfoter.

Friday, September 02, 2005

Much Ado About MDs

It seems like there's a new wave of M.D. shows on TV. With the demise of Chicago Hope and E.R., and only Becker surviving the times, we now have two brand new, swanky doctor shows - SCRUBS and HOUSE.

Image hosted by Photobucket.comFor the unacquainted, SCRUBS revolves around a few interns with overactive imaginations, hip lives, and a great zest for people. In short - a myth. But, hey, who among us MDs don't wish our lives were a little like that. I liked today's episode on Astro, actually, where a dying patient taught an intern that it was ok to rest.

That he needed to give himself permission to go lie on the grass and relax for awhile. We MDs do become so obsessed and entrapped in our work sometimes as not to be able to see the bigger picture or to find ourselves apart from it.

Image hosted by Photobucket.comHOUSE, on the other hand, glorifies a team of diagnosticians whose expertise is solving the unsolvable cases. Those that, in our real life hospitals, normally go quietly unsolved. Labelled 'SEPTICEMIA' or 'M.I.'. These guys however, come up with high flung diagnoses like cerebral cysticercosis, or colchicine-poisoning. I understand that the whole point of this series is that - the diagnostic genius of Dr. House and his dream team. What is unrealistic is how these guys run ALL the lab tests themselves! From gene sequencing to viral antibody titres! That's really taking it too far.

What I DO like about it, is the FED-UPness of House (which is true of all of us after seeing one patient too many) and the METICULOUSNESS of his problem-solving. I've seen more than one technique that we actually employ in real life, being used. One is the acronym for pathologies - he uses MIDNIGHT (for metabolic, infective, degenerative, neoplastic, etc.), and the other is the Venn diagram for looking for the disease that accounts for ALL presenting symptoms. Also the mention of Occam's razor was very gratifying to me - the simplest explanation is most likely the correct one.

As doctors we may pooh-pooh the idealism, unreal-ness, or far-fetchedness of some of the stories, but let's not deny that in some way it validates our lives as human beings. That's what I like about these shows - they portray us frail, vulnerable, and confused like everyone else. And even if it doesn't change public perception, I hope it helps us to accept ourselves better.

Wednesday, June 22, 2005

What do we know?

Anthony de Mello once said: 'When you come to see you are not as wise today as you thought you were yesterday, you are wiser today,' and 'Wisdom tends to grow in proportion to one's awareness of one's ignorance.'

We physicians pride ourselves with our knowledge. We have conquered anatomy, physiology, biochemistry and all the clinical theory we can possibly learn in five years of medical school. Then we have specialised and again grappled with enormous amounts of scientific facts and applied them to our patients. When our patients ask us questions, we steel our faces and speak with authority. We know. We are all wise.

Even the language we use every day betrays that assumption. The word diagnosis means to know (gnosis) through-and-through (dia). And prognosis is to know in advance! How many professions claim to know even the future! How we pride ourselves with our knowledge.

Ironically, sometimes it is this knowledge that keeps us from truly learning and knowing. When I had finished my exams a year ago, the feeling was quite different. I had just been certified by a conjoint board of experts that my knowledge and skill was befitting that of a specialist. I overflowed with knowleedge, there was nothing I couldn't handle. Only a year but many difficult cases later, I have to admit I know nothing.

What do we really know? The evolution of medical science is testimony to how much we didn't know 10 years ago, and what we think we know now will be laughable in just 5 years. And what do we know of our patients besides the labels we give them? How does the man with cancer feel about his disease? What motivates him to seek treatment? What about death - how will he face it? How do our patients make sense of disease and death, where do they find meaning, how do they carry on? I think I have more to learn from them than I have to offer.

As a physician I have been given the privilege to be in such close contact with the rawest of human experiences - pain, suffering, death. What is the purpose of these? What were they put here to teach? What have I learnt? Are there clues about life and living that I have missed? Perhaps it is in the throes of suffering and inexplicable pain that we can find some answers.

But beyond that, there must be a sense of mystery. For what is science, what is medicine without uncertainty and mystery to keep us plodding and searching? Perhaps when I let go of what I know for a while, I might actually begin to learn...

"What, concretely, is Enlightenment?"
"Seeing Reality as it is," said the Master.
"Doesn't everyone see Reality as it is?"
"Oh, no! Most people see it as they think it is."
"What's the difference?"
"The difference between thinking you are drowning in a stormy sea and knowing you cannot drown because there isn't any water in sight for miles around."

Tuesday, June 14, 2005

'Public Support for Stem Cell Research Remains High'

'Differences widen between supporters and detractors,' Harris poll finds

From Harris Interactive:

Most adults, regardless of party identification or religious affiliation, believe embryonic stem cell research should be allowed. Support has remained high over the past year as nearly three-quarters (74 percent) of U.S. adults believe stem cell research should be allowed today (73 percent in 2004).

"While support for stem cell research has remained steady overall, the number of Republicans and born-again Christians opposing stem cell research has risen over the past year and fewer are uncertain about their position on the issue.

"Today, one in four (25 percent) Republicans, compared to one in five (18 percent) one a year ago, believe that stem cell research should not be allowed. The proportion of Republicans who are unsure has declined to 15 percent, down from 21 percent in 2004. Three in ten (29 percent) born-again Christians, compared to two in ten (21 percent) just one year ago, believe that stem cell research should not be allowed....

"Other key findings from the survey include:

"A majority (72 percent) of adults tend to agree that as long as the parents of the embryo give their permission, and the embryo would otherwise be destroyed, stem cell research should be allowed; this is unchanged from 2004.

"Nearly two-thirds (65 percent) of adults tend to agree that if most scientists believe that stem cell research will greatly increase our ability to prevent or treat serious diseases we should trust them and let them do it; this is virtually unchanged from 2004 (67 percent)....

"Majorities of adults continue to reject two arguments used by those who oppose stem cell research. Two in three (66 percent) tend to disagree that allowing any medical research using stem cells from human embryos should be forbidden because it is unethical and immoral, and 58 percent tend to disagree that using cells from human embryos for research comes too close to allowing scientists to play God...."

Tuesday, June 07, 2005

The Learning Paradigm

Peter Sheppard teaches in his book, Life Matters the 'Learning Paradigm', which consists of:
1. What? - Concepts, facts
2. Why? - Principles
3. How we feel - Values, Attitudes, Motivation
4. How we apply - Skill, Technique, Method

Confucius says: What I hear, I forget, what I see, I understand, what I do, I remember.

Einstein says: I don't teach, I create the environment conducive for learning.

I remember how in med school, too much time and energy was spent on teaching and learning the facts which could have been easily gleaned from textbooks and even more quickly committed to memory if I was better motivated.

As a med lecturer now I am guilty of doing the same thing. Vomiting lists and tables and making their accurate regurgitation my end goal.

How artless this kind of teaching!

I'd do better helping my students find their personal motivation, whet desire and excitement to learn, and empower them by giving them things to do, ownership of their careers.

I should start contact by getting them to articulate their personal motives - if you had no exams what and why do you want to learn? What are weaknesses you want to work on? Make a commitment to concrete and measurable steps.

Then we should articulate a learning contract - I will be there for you but you will do the necessary work to educate yourself.

Next I will give them patients to 'own' - they will 'advise' me on how to treat them and I will allow them to do as much as possible in their incrementing scope of responsibility.