It's almost instinctive – you count the number of candles on the birthday cake, and you start to gauge the age of its owner.
Which makes perfect sense. I should have forty on mine yesterday. With time, I learn to tell my friends that chronological age has nothing to do with one's real age. During the lunch conversation yesterday, my friend didn't believe that I remain young, and then looked me straight at a scar on my face.
Before she asked, I knew she wanted an explanation or the story behind it. I smiled cheerfully. "Oh good," I said. "My daughter is getting more energetic and charges ahead boldly. She waved her hand and scratched my face few weeks ago. You know, a nine-month-old has literally great leaps of faith, causing wounds here and there. Five minutes after the tenth topple, she's ready for number eleven."
"True. A kid's wound heals and vanishes quickly, unlike yours," my friend reminded me. "And perhaps that is the difference between Jasmine's wound and her father's scar. When you're no longer young, the wound lasts."
Wednesday, September 29, 2010
Sunday, September 12, 2010
Reaction
If outsiders had to describe mistakes in medicine, they might use words like reckless, thinking of the seemingly endless stories of poor patients who suffered. Or, if they read the local newspaper, they could call it unacceptable, with a nod to the call for disciplinary action. Who could possibly object?
Actually, lots of people. After a recent headline story highlighting our loss of a patient's life in the hospital, there are some, of course, who seriously blame a doctor who prescribed too low a dose of anticoagulant drug supposed to prevent the dangerous blood clots that can travel to the brain, causing stroke. That is, broadly, the usual reaction from the mass media. But one important fact is left out of the scene – and that is the image of doctors. When people are being asked to say which professionals deserve the most respect, they usually put doctors at the very top of the list, way above clergymen and lawyers.
We agree that doctors are no longer free to practice away from the cruel scrutiny of the news media, not to mention the constant erosion of the trust in doctors. Admittedly, their biased emphasis can make it look like a nefarious crime scene, accusing doctors of having "committed the worst blunders, if not murder." I know, I know, that's disheartening. But let's think about how our patients – not the mass media – react. They are forgiving, if you ask me. In a way, we're fortunate to work with the growing realization that doctors are fallible. And that's why doctors are more open to our own mistakes. I'm one of them.
I will never forget the forgiving look on the face of my kidney transplant patient who nearly died because of my mistake. It all started with my prescribing him allopurinol, a pill supposed to work for his repeated attacks of gout. But I forgot the precarious drug interaction between allopurinol and another medication that he had been taking after the transplant. Because of that, the work of his bone marrow came to a halt and the number of his white blood cells dwindled to a dangerous level. This was only picked up by my colleague few months later. My patient was simply told that he wasn't tolerating the medication; there was no mention of medical mishap. My first instinct, after hearing what had happened, was not to sweep the mistake under the rug. I called back my poor patient and told him everything, I mean, my careless mistake. This may seem impossibility, but it is true, and he accepted my apology. He reminds us how far we've come and how lucky we are.
Actually, lots of people. After a recent headline story highlighting our loss of a patient's life in the hospital, there are some, of course, who seriously blame a doctor who prescribed too low a dose of anticoagulant drug supposed to prevent the dangerous blood clots that can travel to the brain, causing stroke. That is, broadly, the usual reaction from the mass media. But one important fact is left out of the scene – and that is the image of doctors. When people are being asked to say which professionals deserve the most respect, they usually put doctors at the very top of the list, way above clergymen and lawyers.
We agree that doctors are no longer free to practice away from the cruel scrutiny of the news media, not to mention the constant erosion of the trust in doctors. Admittedly, their biased emphasis can make it look like a nefarious crime scene, accusing doctors of having "committed the worst blunders, if not murder." I know, I know, that's disheartening. But let's think about how our patients – not the mass media – react. They are forgiving, if you ask me. In a way, we're fortunate to work with the growing realization that doctors are fallible. And that's why doctors are more open to our own mistakes. I'm one of them.
I will never forget the forgiving look on the face of my kidney transplant patient who nearly died because of my mistake. It all started with my prescribing him allopurinol, a pill supposed to work for his repeated attacks of gout. But I forgot the precarious drug interaction between allopurinol and another medication that he had been taking after the transplant. Because of that, the work of his bone marrow came to a halt and the number of his white blood cells dwindled to a dangerous level. This was only picked up by my colleague few months later. My patient was simply told that he wasn't tolerating the medication; there was no mention of medical mishap. My first instinct, after hearing what had happened, was not to sweep the mistake under the rug. I called back my poor patient and told him everything, I mean, my careless mistake. This may seem impossibility, but it is true, and he accepted my apology. He reminds us how far we've come and how lucky we are.
Saturday, September 4, 2010
What's Wrong
One day, while discussing the mystery of our patient at the hospital corridor, my colleague who has a passion for automobile mechanic cautioned, "Oh man. If we want to be honest, let me ask you how many times are we doctors certain with what's wrong with our patients?"
Slushy nonsense? Not a bit of it! For some reason I'm amazed at his cruel and frustrating (though certainly true) statement. Consider an eightysomething man who came to the hospital with a bit of cough and not in his usual shape. Each numerical figure in his laboratory results was not very normal, but not too bad. At the end, for the hundredth time, for the thousandth time, the diagnosis, often loopy, would be a chest infection. It's hard to imagine any better diagnosis to be typed in the discharge summary.
Which brings me to the analogy of an auto mechanic, this time attributed to David H. Newman. Consider going to an auto mechanic about an unsettling sound coming from the car. The mechanic also suspected something (but not sure which) wrong. He then shrugged and produced a pair of earplugs - alas, quite similar to what we prescribe - and said, "Wear these while you drive."
Slushy nonsense? Not a bit of it! For some reason I'm amazed at his cruel and frustrating (though certainly true) statement. Consider an eightysomething man who came to the hospital with a bit of cough and not in his usual shape. Each numerical figure in his laboratory results was not very normal, but not too bad. At the end, for the hundredth time, for the thousandth time, the diagnosis, often loopy, would be a chest infection. It's hard to imagine any better diagnosis to be typed in the discharge summary.
Which brings me to the analogy of an auto mechanic, this time attributed to David H. Newman. Consider going to an auto mechanic about an unsettling sound coming from the car. The mechanic also suspected something (but not sure which) wrong. He then shrugged and produced a pair of earplugs - alas, quite similar to what we prescribe - and said, "Wear these while you drive."
Wednesday, September 1, 2010
Mechanic
"An auto mechanic's job is no different from a doctor's." That's a fair comment from a colleague of mine during dinner.
To pursue the mechanic analogy, he enthused, "Think about it. We were told the symptoms such as acute diarrhea or cramps, which are presumably external signals of a diseased or malfunctioning organ. A doctor examined the faulty organ whereas a mechanic rummaged around under the hood, figuring out a list of hypotheses to be tested one by one. Sooner or later, we're zeroing in on the ultimate problem. Case closed."
Tempting it is to think that such analogy is a true statement. That's not the right way; really, if you ask me, wrong. To say that a doctor can solve a problem under the hood, as what a mechanic does, would conjure up the image of physicians or surgeons who never talk. For goodness' sake, have you heard a mechanic talking to the automobile engine, "Good morning, how is the day?"
The problem isn't that the auto mechanic needs to talk, it's that a patient is simply different from Mercedes-Benz. A sick engine never responds to soothing voice or empathetic nod; our patients will. And the effect is riveting.
To pursue the mechanic analogy, he enthused, "Think about it. We were told the symptoms such as acute diarrhea or cramps, which are presumably external signals of a diseased or malfunctioning organ. A doctor examined the faulty organ whereas a mechanic rummaged around under the hood, figuring out a list of hypotheses to be tested one by one. Sooner or later, we're zeroing in on the ultimate problem. Case closed."
Tempting it is to think that such analogy is a true statement. That's not the right way; really, if you ask me, wrong. To say that a doctor can solve a problem under the hood, as what a mechanic does, would conjure up the image of physicians or surgeons who never talk. For goodness' sake, have you heard a mechanic talking to the automobile engine, "Good morning, how is the day?"
The problem isn't that the auto mechanic needs to talk, it's that a patient is simply different from Mercedes-Benz. A sick engine never responds to soothing voice or empathetic nod; our patients will. And the effect is riveting.
Thursday, August 26, 2010
Faux pas
As unseemly as it might appear, a patient's thank you card can be very encouraging to a doctor. Not all doctors derive comfort from such a small token of appreciation - but many do.
On a lovely August day, I received a card from my patient's family. This reminded me of that patient's recent bleeding complication after colonoscopy at another hospital. His wife requested me to speak to his surgeon. I did. His surgeon told me what happened, cautiously remarking that bleeding was under control after the second colonoscopy procedure and tranexamic acid, a medication that has been touted as a brake to the domino effect of catastrophic bleeding. When I learned more about the medication dose that my dialysis patient had received, I told the surgeon to stop it and send the patient to see me. With my patient's poor kidney function in mind, I worried that the drug would accumulate pretty quickly in his body.
My patient didn't manage to walk into my clinic the next day - he was shaky and stuttering in a wheelchair, after being intoxicated by the magic drug. He wasn't back on his feet for at least three days.
Few weeks later, I met my patient's wife who sent me the card. In passing, she told me that she owed me her life, too, when she happened to be under my care ten years ago. "Did I?" I responded, pride written all over my face. "I didn't recall seeing you."
"Believe it or not, I collapsed after being given a shot for my abdominal colic, and was then sent to the emergency room. Too much of the injection dose, I guess. You were the one who saved me at that time."
I listened, nodded and blushed. "Mm-hmm," I thought. "We're praised for making remedies for medical errors. That's embarrassing."
On a lovely August day, I received a card from my patient's family. This reminded me of that patient's recent bleeding complication after colonoscopy at another hospital. His wife requested me to speak to his surgeon. I did. His surgeon told me what happened, cautiously remarking that bleeding was under control after the second colonoscopy procedure and tranexamic acid, a medication that has been touted as a brake to the domino effect of catastrophic bleeding. When I learned more about the medication dose that my dialysis patient had received, I told the surgeon to stop it and send the patient to see me. With my patient's poor kidney function in mind, I worried that the drug would accumulate pretty quickly in his body.
My patient didn't manage to walk into my clinic the next day - he was shaky and stuttering in a wheelchair, after being intoxicated by the magic drug. He wasn't back on his feet for at least three days.
Few weeks later, I met my patient's wife who sent me the card. In passing, she told me that she owed me her life, too, when she happened to be under my care ten years ago. "Did I?" I responded, pride written all over my face. "I didn't recall seeing you."
"Believe it or not, I collapsed after being given a shot for my abdominal colic, and was then sent to the emergency room. Too much of the injection dose, I guess. You were the one who saved me at that time."
I listened, nodded and blushed. "Mm-hmm," I thought. "We're praised for making remedies for medical errors. That's embarrassing."
Saturday, August 7, 2010
Don't Know
I have been learning to make use of the skill to acknowledge what I don't know that I don't know. Knowledge is different from all other kinds of resources, as we have been told, because it constantly makes itself obsolete.
Last week, one of our talented fellows asked me what's the reason of stopping salbutamol, a short-acting "reliever" medication for chest tightness, in case our patients are coughing up blood from the lungs. I took a deep breath and then told her I don't really know. Although I quoted the evidence from an article that appeared in the British Medical Journal 28 years ago, the honest answer should be kind of old wives' tale. That's what I had been taught soon after my becoming a doctor.
Looking back, I reflected on what I had learned about the need to suspend any dogma, however hard earned it may be. Be flexible and admit I don’t have all the answers. To borrow an idea from Nance Guilmartin, the more we think we know, the less we truly know.
Last week, one of our talented fellows asked me what's the reason of stopping salbutamol, a short-acting "reliever" medication for chest tightness, in case our patients are coughing up blood from the lungs. I took a deep breath and then told her I don't really know. Although I quoted the evidence from an article that appeared in the British Medical Journal 28 years ago, the honest answer should be kind of old wives' tale. That's what I had been taught soon after my becoming a doctor.
Looking back, I reflected on what I had learned about the need to suspend any dogma, however hard earned it may be. Be flexible and admit I don’t have all the answers. To borrow an idea from Nance Guilmartin, the more we think we know, the less we truly know.
Wednesday, August 4, 2010
Murmur
Medical students don't want to miss out on examining patients with abnormal heart sounds or heart murmurs, because these patients often appear in the final examination. The students are expected to feel the pulse, listen with the stethoscope, and then come up with an answer to the question of which heart valves are leaking or narrowing.
The examination is not for the faint-hearted. I saw beads of perspiration over my student's forehead when I led her to examine a lady with narrowing of the aortic valve. I had a hunch (and it later proved to be pretty accurate) that my student’s heart was doing pirouettes in tandem with the noises of the patient’s heart.
When I debriefed the medical students about the lessons learned, I told them an important tactic. "Pause," I said. "What’s the most important thing to a patient when a doctor or student comes into the room – before you stick that needle in or take out the stethoscope? Stop, and see him as a person first and a patient second. A gentle greeting with a smile would do. As simple as that. Make your patient (and yourself) comfortable."
That's what I learned from my patients and recent reading of Nance Guilmartin's book.
The examination is not for the faint-hearted. I saw beads of perspiration over my student's forehead when I led her to examine a lady with narrowing of the aortic valve. I had a hunch (and it later proved to be pretty accurate) that my student’s heart was doing pirouettes in tandem with the noises of the patient’s heart.
When I debriefed the medical students about the lessons learned, I told them an important tactic. "Pause," I said. "What’s the most important thing to a patient when a doctor or student comes into the room – before you stick that needle in or take out the stethoscope? Stop, and see him as a person first and a patient second. A gentle greeting with a smile would do. As simple as that. Make your patient (and yourself) comfortable."
That's what I learned from my patients and recent reading of Nance Guilmartin's book.
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