Yesterday morning, my students asked me reasons for the way certain diseases behave. "This is the way it is," I answered. "All that is ever asked of you is that you have to remember it."
This is my mantra – one I seldom follow.
Despite my teaching others to memorize this and that, I have to admit that my own memory is in decline. There is no question that creativity declines throughout all those years in the medical school. Hey, decline in creativity after rote learning is natural; what else do you expect? Most of us take it for granted, akin to the way a man thinks about the growth of the belly circumference – it simply grows with our age.
But - and this is the point - when it comes to the decline in our memory, we feel like an old man regretting and bemoaning his receding hairline. My brow furrowed and the crow’s feet deepened as I struggled to keep myself from forgetting things. Alas, I went to the post office yesterday and picked up my registered mail, and simply forgot to collect the stamps. Uh-oh. Whenever I quoted something like "a recent study published last month in the New England Journal of Medicine" during the rounds, it would turn out that the paper appeared in the Journal few years ago. As the months and years went by, I realized that I am the victim of dementia. And what makes it worse – it's the sort of disease for which there's no cure! Out loud I say, "I can't even remember when was the last time I remembered correctly."
Sunday, February 22, 2009
Monday, February 16, 2009
Jerome Groopman
In many ways a doctor keeps stories behind their back – stories he's a part of, stories that happen to patients he take care of, stories that he has to live with after sleepless nights, stories nagging at him in the dark places of his mind. So I was not surprised to learn that Jerome Groopman, one of my favourite medical doctor writers for The New Yorker, has been haunted by his own tale.
Having finished his book How Doctors Think, I've learned his story of looking after a middle-aged woman with a litany of complaints. After listening to a new complaint of discomfort in her upper chest, Dr. Groopman made a diagnosis of acid regurgitation from the stomach, and couldn't think in a different way. Several weeks later, his patient died of aortic dissection, a life-threatening condition when a tear happens to the giant artery that carries oxygenated blood from the heart to the smaller blood vessels throughout the body.
Simple as the case may seem to us in hindsight, many of us – certainly I include myself – could have been fooled and regret afterward. I do not wish to compete for a trophy in making wrong diagnosis. I'm simply trying to understand the corrosive mixture of shame and guilt that I learned to feel after hearing the story of Dr. Groopman.
Not long ago, I met an extremely fit man who attended the emergency room after a growing weakness in his legs. He didn't recall injury but he mentioned numbness. The admission team arranged an x-ray and an MRI scan of his spine. That's the way to find out if the large bundle of nerves (that run from the brain to the bottom of the back) is being compressed. I'd already had the MRI reports in the patient file when I first met him. I asked myself what was wrong with this patient. "Ugh. I really don't know, if they can't see evidence of acute spinal cord compression." I then pondered the possibility of a neurological condition in which spinal cord inflammation leads to the disruption of its communication to the legs, and thus problem with moving and feeling his legs. After putting a needle into his lower back to get a sample of fluid surrounding the spinal cord, I found nothing abnormal.
Two days later, a young doctor, who had bothered to take a good look at the MRI films instead of the radiologist's report, discovered an all-too-obvious tear at the large blood vessel, alas, shutting off the blood supply to the patient’s spinal cord.
I kicked myself for missing another case of aortic dissection, but it's too late.
Having finished his book How Doctors Think, I've learned his story of looking after a middle-aged woman with a litany of complaints. After listening to a new complaint of discomfort in her upper chest, Dr. Groopman made a diagnosis of acid regurgitation from the stomach, and couldn't think in a different way. Several weeks later, his patient died of aortic dissection, a life-threatening condition when a tear happens to the giant artery that carries oxygenated blood from the heart to the smaller blood vessels throughout the body.
Simple as the case may seem to us in hindsight, many of us – certainly I include myself – could have been fooled and regret afterward. I do not wish to compete for a trophy in making wrong diagnosis. I'm simply trying to understand the corrosive mixture of shame and guilt that I learned to feel after hearing the story of Dr. Groopman.
Not long ago, I met an extremely fit man who attended the emergency room after a growing weakness in his legs. He didn't recall injury but he mentioned numbness. The admission team arranged an x-ray and an MRI scan of his spine. That's the way to find out if the large bundle of nerves (that run from the brain to the bottom of the back) is being compressed. I'd already had the MRI reports in the patient file when I first met him. I asked myself what was wrong with this patient. "Ugh. I really don't know, if they can't see evidence of acute spinal cord compression." I then pondered the possibility of a neurological condition in which spinal cord inflammation leads to the disruption of its communication to the legs, and thus problem with moving and feeling his legs. After putting a needle into his lower back to get a sample of fluid surrounding the spinal cord, I found nothing abnormal.
Two days later, a young doctor, who had bothered to take a good look at the MRI films instead of the radiologist's report, discovered an all-too-obvious tear at the large blood vessel, alas, shutting off the blood supply to the patient’s spinal cord.
I kicked myself for missing another case of aortic dissection, but it's too late.
Saturday, February 14, 2009
Habit
Almost everyone follows his or her own routine meticulously, so there's a good chance that you do too. And why not? Admit it. We have our own rituals of daydreaming, doing grocery, writing blogs, and even visiting the john.
Trust me, I am no expert on following the routine doggedly. But I've been keeping a habit weekly; I read the New England Journal of Medicine every Thursday for years. In particular, I never miss the case records of Massachusetts General Hospital or Clinical Problem-Solving feature published in the Journal. This weekly clinicopathological exercise is a mind boggling game climaxed by thorough discussion from renowned clinicians, showing us how doctors sleuth for the footprints to a mysterious diagnosis.
Which brings me to a tongue-in-cheek comment by a discussant in the recent case record, "As rheumatologists, we become comfortable with our inability to render precise diagnoses in all patients." This opens my eyes to the truth that we should frankly admit our ignorance. If you take a deep breath and a step back, I think you'll agree with me that, in a way, this sentence should be remembered by every doctor.
Trust me, I am no expert on following the routine doggedly. But I've been keeping a habit weekly; I read the New England Journal of Medicine every Thursday for years. In particular, I never miss the case records of Massachusetts General Hospital or Clinical Problem-Solving feature published in the Journal. This weekly clinicopathological exercise is a mind boggling game climaxed by thorough discussion from renowned clinicians, showing us how doctors sleuth for the footprints to a mysterious diagnosis.
Which brings me to a tongue-in-cheek comment by a discussant in the recent case record, "As rheumatologists, we become comfortable with our inability to render precise diagnoses in all patients." This opens my eyes to the truth that we should frankly admit our ignorance. If you take a deep breath and a step back, I think you'll agree with me that, in a way, this sentence should be remembered by every doctor.
Saturday, February 7, 2009
Basic
As mentioned, I took a recent trip to New Zealand’s national park. On the coastal trail in the park, I carried with me the sleeping bag and stayed in the basic hut.
I said that the hut is basic, and it is. In a nutshell, bunk bed and mattress. We didn't have to share shower facility or electricity because there is simply none. Not much to share with each other really, except the sound of someone snoring.
You're probably thinking that I was having trouble to stay there, but I wasn't. For most of my memorable years after graduation from medical school, I used to sleep like a primitive man at the Stone Age. I simply slept around a humble corner at my hospital – be it the sofa at the office or the patient's bed at day care centre. For goodness' sake, I didn't have to hide from predators as in ancient time, but had to wake up before six thirty, when the hospital amah comes back in the morning.
After all these years, I cherish the gypsy memories of sleeping at any place I can find. Not that sleeping in a basic hut or a corner in the hospital is cozy in itself. The idea is that we might be happier not to bother too much, or, in Henry Thoreau's words, "Man is rich in proportion to the number of things he can do without." I have come to believe it's so.
I said that the hut is basic, and it is. In a nutshell, bunk bed and mattress. We didn't have to share shower facility or electricity because there is simply none. Not much to share with each other really, except the sound of someone snoring.
You're probably thinking that I was having trouble to stay there, but I wasn't. For most of my memorable years after graduation from medical school, I used to sleep like a primitive man at the Stone Age. I simply slept around a humble corner at my hospital – be it the sofa at the office or the patient's bed at day care centre. For goodness' sake, I didn't have to hide from predators as in ancient time, but had to wake up before six thirty, when the hospital amah comes back in the morning.
After all these years, I cherish the gypsy memories of sleeping at any place I can find. Not that sleeping in a basic hut or a corner in the hospital is cozy in itself. The idea is that we might be happier not to bother too much, or, in Henry Thoreau's words, "Man is rich in proportion to the number of things he can do without." I have come to believe it's so.
Tuesday, February 3, 2009
Abel Tasman
I had just returned from the Abel Tasman National Park Coast Track at New Zealand. Situated on South Island's northern shores, it was a long walk over 36 km, with primitive huts for stay overnight.
There is a wealth of awesome tramping tracks in New Zealand but this one is indeed classic. Throughout the track along the coastline, there are quite a number of tidal crossings which can only be passed within a few hours either side of low tide. That means we have to consult a tide timetable when planning the trip across those estuaries, lest the high tides block the track.
To stop myself treading water and wasting time at high tide, I ended up waking before sunrise to leave the hut and start my walk on the second day. Oh, that wasn't a big deal as the sleeping quality at those huts isn't what one would savour. And the tidal crossing turned out to be a revelation.
As I headed across the estuary at low tide in the wee hours of the morning, amidst the songs by bellbirds, fantails and tui, it was with some relief I read from the signpost that the detour route, in case of high tide, would have taken me extra three hours of walk.
Does that sound similar to what we did in mundane world?
I think there's a good deal of similarity between tidal crossing and the day-to-day challenges we face – big ones and small ones alike. The mortgage of our properties, the level of difficulty in any examination and, obviously, the Hang Seng Index, all come with high tide and low tide. Do not mistake my point here. In no sense do I advocate taking short cuts. All of us, no matter how hardworking and diligent, must be ever aware of the possibility of hitting at the high tide. And, for that matter, the time of tide in this universe varies from day to day, and we can't make the low tide comes earlier (not least because the tide timetable doesn't exist at all in most circumstances).
And therein lies a lesson, for which I keep reminding myself and others. A doctor who takes longer to get his or her membership qualification doesn't necessarily perform worse than anyone else; he or she might have simply hit the high tide during the professional examination.
There is a wealth of awesome tramping tracks in New Zealand but this one is indeed classic. Throughout the track along the coastline, there are quite a number of tidal crossings which can only be passed within a few hours either side of low tide. That means we have to consult a tide timetable when planning the trip across those estuaries, lest the high tides block the track.
To stop myself treading water and wasting time at high tide, I ended up waking before sunrise to leave the hut and start my walk on the second day. Oh, that wasn't a big deal as the sleeping quality at those huts isn't what one would savour. And the tidal crossing turned out to be a revelation.
As I headed across the estuary at low tide in the wee hours of the morning, amidst the songs by bellbirds, fantails and tui, it was with some relief I read from the signpost that the detour route, in case of high tide, would have taken me extra three hours of walk.
Does that sound similar to what we did in mundane world?
I think there's a good deal of similarity between tidal crossing and the day-to-day challenges we face – big ones and small ones alike. The mortgage of our properties, the level of difficulty in any examination and, obviously, the Hang Seng Index, all come with high tide and low tide. Do not mistake my point here. In no sense do I advocate taking short cuts. All of us, no matter how hardworking and diligent, must be ever aware of the possibility of hitting at the high tide. And, for that matter, the time of tide in this universe varies from day to day, and we can't make the low tide comes earlier (not least because the tide timetable doesn't exist at all in most circumstances).
And therein lies a lesson, for which I keep reminding myself and others. A doctor who takes longer to get his or her membership qualification doesn't necessarily perform worse than anyone else; he or she might have simply hit the high tide during the professional examination.
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