ZEBRA HUNTER

One of the first pieces of advice I remember was that the difference between a new doctor and experienced one is the approach to a clinical question. The new doctor starts with a wide differential, gathering information to narrow it down, whereas the intuitive, experienced doctor immediately has a general sense of the answer and gathers information to justify the suspected diagnosis.

I have been keenly aware of my changing perspective over the years, noticing every so often that I've shifted a tiny bit more toward the latter (not only did I not truly understand the true meaning of the statement initially, I didn't understand the timeline- it's not an overnight change of perspective, unfortunately).  My ignorant, egocentric first thoughts were that I, of course, was exempt- I knew it all already....

DON'T BUY ALL THE BOOKS!

Now that I'm 7/8 of the way done with med school, I'm starting to compile some of my better advice, and hopefully one day can publish it.  Here's an excerpt; not that anyone ever comments, but if anyone has suggestions or requests, let me know!

Like college textbooks, medical texts can be outrageously pricey. Embarrassingly, I was “that person” who purchased every single book on the “required book” list.  I think it was probably around $2000. (Yes, I bought them new from Amazon.)  Sitting in orientation surrounded by people complaining about said booklist and realizing that I was literally the only one who had purchased any books at all, I vowed to pass on the word.

PAIN, PART 2

Facts about narcotics that doctors assume patients know (and therefore don't address):

• Narcotic medications are addictive. Period. Even if you really need them, you can still be addicted. There was a big scandal recently which revealed that some drug companies had mislead doctors and patients about the dangers and addictive qualities of narcotics, so everyone needs to be aware.
• "Narcotics" aren't just illegal drugs like heroin. Narcotics are also those "pain pills" you get as a prescription. Sometimes the doctor asks if you've ever been dependent or addicted to drugs- THESE COUNT, and doctors assume you've never had a problem if you say no.
• TOLERANCE: The more narcotics you take, the more your tolerance builds up. Then when you experience even more pain, you need more medication. It's excruciating to watch people who are dependent on narcotics after surgery or an injury experience excruciating pain that we can't control because your body has such a high tolerance....

PAIN, PART 1

Being in a surgeon's office this week has really made me reflect about the wide variation of pain perception. Clearly, assessing and treating pain presents major quandary for physicians- who is really in pain? Whose pain are we missing? Are we killing people by over-managing pain?

I've heard the surgeon discuss narcotic pain medications multiple times with patients this week, and the bottom line is evident: doctors often do a horrible job of screening for pain (I'll place most of the blame on a lack of tools, because there's no magic lab test or xray) but also explaining the proper use of narcotics and the risks of inappropriate or long-term use.

Narcotics are a big pet peeve of mine (not when used "correctly" of course, but even that's not well-defined). Volumes of books could be written on this subject (and have been) so ill try to be brief (and also divide this up into multiple posts).

This is a bit like discussing politics around election time, so I'll try to be as objective as possible (which is impossible)....

TAKE A HIKE, SAVE YOUR BRAIN

Doing crossword puzzles was my "morning coffee" during college- the absolute only thing that kept my forehead off the desk in 8am classes. I justified it by convincing myself that word puzzles were just as important to keeping my neurons happy and healthy as the chemistry I was unable to concentrate on.

Well, it turns out that might not be true....

UNDEADING

So you're driving down the road, and look ahead to see some idiot slowly crossing the road. My first response has always been utter exasperation and wonder- don't they know they're going to get hit?

This morning when I saw that, I had a revelation: Maybe they just don't care.

I never had this thought before medical school, and it still greatly bothers me when it goes through my head (so don't feel the need to call a shrink on me or anything). But long days, hazing, frequent ridicule and a (relatively) bleak near-future, and suddenly you have the occasional fleeting thought that you might NOT care if a car hits you when you cross the road. I don't think that thought even counts as passive suicidal ideation (again, that might be relative), especially If you're on certain rotations in medical school, like cardiothoracic surgery.

Life can be tough....

GREAT MINDS...without chairs

So, a while back I posted about chair hierarchy in the hospital. Someone else (who clearly has better artistic ability) had the same thought!!!

It's a bird! It's a plane! No...it's the correct diagnosis!

Excerpts taken from Dr. Bernard Lown's The Lost Art of Healing:

"[The physician] urged us, as beginning medical students, never to prescribe for a chief complaint unless we had come to know the patient well and figured out what was truly troubling the person. A physician committed to healing could not and should not focus exclusively on a chief complaint, or even a diseased organ. If one was to help those who were sick, the stressful aspects of life had to be exposed."

"Limiting history-taking to the chief complaint often initiates fruitless pursuit of irrelevant matters that are quite tangential to the main problems."

Unfortunately, this happens every day- time constraints result in doctors focusing on the one chief complaint, and the underlying problem is never addressed. Medications, "bandaids," often cause more harm than good, and these patients end up undergoing a battery of unnecessary treatment and tests.

A solid HPI is essential to establishing a correct diagnosis but is rarely conclusive, and should naturally lead to a detailed social history which provides context for the "chief complaint."  The easiest and fastest way to handle multiple complaints is to send someone to a specialist.  So the depressed patient who comes in for back pain, headaches and low energy gets referred to an orthopedic surgeon, neurologist and endocrinologist (or cardiologist!), when an extra 10 minutes gathering history (recent death of spouse, or lost job) would result in a logical, easily-managed diagnosis.  In fact, the 2 or 3 weeks of trialing an anti-depressant would likely be faster than making an appointment with a specialist, and clearly would be less stressful and much less expensive for the patient.

Clinicians get sucked into the idea that we have to explore every possible cause (again, thanks to lawsuits), but why are we still looking for zebras??  Modern technological advances have unfortunately created a safety net for poor history-taking and physical exams.  Just because we CAN find more zebras doesn't mean we SHOULD!

My advice to a patient (or potential patient), would be to tell your doctor EVERYTHING! (If your doctor won't listen, get a new doctor.)  Many people don't associate their chest pain with their family feud, or their headaches with caffeine withdrawal.  If your doctor doesn't know about your stress or your quitting coffee cold turkey, they might forget or not have time!  While I'm far from condoning "quick" histories, I think patients have to help out and pick up some of the slack, unfortunately.

Patients are their own best advocates, and it's tough to speak up sometimes. Clinicians have to do a better job of making them feel comfortable asking questions or questioning a medication, procedure or even a diagnosis (within reason).