Take My Words

A friend of mine recently told me that we doctors are keen on using abbreviations. Very true. Two types of languages exist in this planet: language used by mankind and the language medical doctors speak.

Doctors speak different language, a fact we must admit before any meaningful dialogue can be carried on. I was reminded of the occasions when my patient developed a stroke without obvious cause. "Mr. X, I’m sorry to tell you that your dad suffers from a cryptogenic stroke." Or, as most of doctors have done before, "Ms Y, this might sound a frightening disease with sudden violent body shaking and foaming at the mouth. Blah, blah, blah. The condition is known as idiopathic epilepsy." Your doctor said it in the it’s-a-big-diagnosis-and-leave-me-no-question tone. You want to believe in him. You have to. You have to trust the doctor within the ten-minute appointment that had taken you ten months – if not more - to schedule.

What an excellent language! Can you imagine we have the words like "cryptogenic" and "idiopathic", which essentially mean "I don’t know the reason"?

I don’t know how you would feel when the encounter changes from a medical doctor to a mechanic, who frowns upon the breakdown of your Volvo and then comes up with a brilliant diagnosis of "idiopathic vehicle breakdown." Instead of fixing the car, the mechanic can learn from the vocabulary of medical doctors. Clearly, he will feel relieved to tell his customer that the problem is an "idiosyncratic" one, rather than making an abject apology that "the problem will simply come and go at any moment – the frequency and timing of which we can’t predict."

My salute to the medical school where I learned the splendid words "idiopathic", "cryptogenic" and "idiosyncratic." Learn to greet every problem, from the alpha to the omega, with these big words, somehow managing to sound knowledgeable with them, and you will qualify as a fully competent doctor.

Blunder

Not long ago, a survey in Massachusetts General Hospital told us that nearly half of doctors admitted to witnessing a serious medical error but not reporting it. According to another survey published this week, most doctors in three United States teaching hospitals agreed that reporting errors improves quality of care, although only a little over half said they understood how to do so; only 18% said they had actually reported a minor error and 4% a major error.

How can this be, I muse, that reporting medical errors lead to improved quality of care? As appealing as such contention seems, I am loath to suggest that reporting medical errors is the reason for improved medical care. This reminds me of a project Early Childhood Longitudinal Study that I learned from the book Freakonomics. This monumental project was undertaken in the late 1990s when more than twenty thousand children from kindergarten through the fifth grade were followed up in the United States, with measurement of the students' academic performance. As it turns out, a spanked child is associated with better test scores. Taken at face value, this would have appeared to advocate parenting with the dogma "spare the rod and spoil the child". Upon second thought, the survey included direct interviews with the children’s parents. Imagine a parent who would have to sit knee to knee with a government researcher and admit to spanking his child. This would suggest that a parent who does so is simply more honest. Honesty, a so-called confounder in statistical term, is in reality more important to good parenting than spanking is to bad parenting. After all, I reason, we should pride ourselves on a hospital where error discussions are valued. The "incidence" of medical errors is going to be the lowest when the system for reporting problems is stacked against the whistle-blower who punishes and ostracizes the doctors reporting medical mistakes.

On the other hand, one might often hear that the hospital with the highest number of medical error reporting is the most malicious one overwhelmed with medical blunders. Such wayward thinking reminds us of another folktale of the czar, who learned that the most disease-ridden province in his empire was also the province with the most doctors. His solution? The almighty czar promptly ordered all the doctors shot dead.

Doctor's Attire

To decipher the behaviour codes of medical doctors at work is a Herculean task – so daunting that I was impressed when I read the blog of my mentor, who recently talked about wearing tie by medical doctors (http://ccszeto.blogspot.com/2008/01/tie.html).

"Isn't it time to write about wearing white coats by doctors?" I talked to myself. Around two years ago, I read from the medical journal that patients and visitors to an internal medicine clinic overwhelmingly favor professional attire with white coats for physicians. Now that the doctor’s creditability is often at stake in the wake of stories in the newspaper, ahem, isn’t this very icon of trust-enhancing white coat attractive? And presto, almost before I realized what I was doing, I found myself for the first time over the last ten years keen to don the great white symbol every time I went to work. It is not a tool to show off the superiority of doctors in front of everyone, and neither is it destined to put our patients’ blood pressure up. Just like the neat, wrinkle-free Boy Scout uniform, the doctor’s white coat represents the spirit of comradeship and serves as a reminder of our discipline or professionalism. Pretty neat, huh? While I pay little attention to my tie, I have never failed to wash and press my white coat every week - as how a Boy Scout would live up to his dictum to keep his uniform laundered and ironed even on the busiest days.

Yet as intuitively appealing as this contention might be, the flip side of the story is that doctors might be fooled into the obsession with mere appearance – instead of concentrating on the scalpel or medical knowledge. Likewise, simply wearing a red towel around the neck and the tights with a trademark "S" will never make us become Superman. And, of course, the white coat nowadays should never be worn for the original purpose of preventing cross contamination, as what it was thought to do back in the 19th century.

So, where does that leave us? Ask yourself this: if a navy personnel or Boy Scout needs to wear uniform with razor-sharp crease, why shouldn't doctors dress in tidy and neat white coats? White coat alone is not meant to be the open seasame to medical doctor. No, it isn't. Still, the very simple act of wearing (or ironing) a clean and unwrinkled white coat, at any rate, will do more good than harm, at least by galvanizing our efforts to pay more attention to our manners and etiquette.

You're Right, I'm Wrong

Some myths really ought to be true. We doctors might react with surprise and pesky feeling when we encounter patients who told us something new and "mysterious". Erosion of patients’ trust follows, if we are ill-equipped to face these "myths".

Insofar as the myths themselves reflect the patients’ interpretation of the illness, their words give us a glimpse of the medicine that we never understand well. The emphasis on learning from doctors and senior, although salutary in numerous ways, has a very dark side to it. We must not forget that we sometimes learn more from our patients than from our professors.

I met a patient who came out from intensive care unit this morning. He smokes, has alcoholism, has been taking methadone for heroin abuse, and is now suffering from tuberculosis causing torrential bleeding from his lungs.

"How is everything going and is the methadone adequate?" I asked.

"Doc, the wound pain is okay," my patient told me nonchalantly. "But the current dose methadone isn’t good enough."

A hint of uncertainty passed over my face. "Are you serious? We don’t cut the methadone dose at all. You have been taking 40 mg every day from the methadone clinic, and we are now giving you 20 mg twice daily."

Before the conversation went out, I then remembered the words from the book "How to Win Friends and Influence People" that I was reading on my way to work this morning.
Show respect for the other person’s opinions. Never say, "You’re wrong".

I promised him that we will look into that and get the right dose for him. I turned to my junior and confessed openly that I am not pretty sure if the drug that we started him for tuberculosis would influence the methadone metabolism.

I went back to my office. The return from my PubMed search after a few mouse clicks goes like this, "Rifampicin (the drug that we used to treat tuberculosis) alterations of methadone effects, leading to withdrawal, are well documented and were linked previously to altered methadone metabolism subsequent to enzyme induction by rifampicin…"