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."

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.

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.

Luddite

Computer technology is incredibly wonderful but never meant to replace humanity, just as knowing about the human genome doesn't give the whole picture of who a person is.

Well, well, well, I seem like an old chap who moans and groans after getting lost in the world of computer. Of course. I am. Maybe I should explain a bit. I was talking about the good old days when I graduated from medical school and did what doctors do – dutifully reviewed the patient's history from scratch and uncovered the hidden story. I learned the ropes of asking questions because there was no computer record for me to scroll up and down frantically. Wait, how did I know my patient's previous abdominal ultrasound study results without computer? Hmm… I couldn't, unless I went down to the radiology department and combed though the cabinet of hand-written reports.

After going through the patient's story, there would be a flurry of questions about what medications were being taken before my patient's coming to the hospital. Once again, I couldn't get the answer without asking questions like, "What's the colour of your blood-thinning medication tablet? And how many brown tablets did you take every day? And, how about that small blue round tablet for slowing down your heart rate? Did you take it every morning?"

While I certainly would have mixed up one medication with another during such primitive way of deciphering, I was convinced that the current computer drug record is equally superficial.

True, the electronic medication record gives us a sense of thoroughness, but this is perhaps the most worrying effect of the technology. As the electronic medical records have been increasingly used in the hospital, we are now tempted to rush to the computer and retrieve all the answers from the screen – but not from the patient's words. Believe me, the meaningless long list of medication on the computer screen never reflects what our patients are actually taking at home. Asking questions is far more powerful than we had ever realized, when it comes to finding out the patient's real medication.

Toy Story

"One of the most obvious facts about grown-ups to a child," Randall Jarrell wrote a century ago, "is that they have forgotten what it is like to be a child."

Yes, that's right. Before I completely forget what it's like to be a child, I went to see Pixar's Toy Story 3 last week. I witnessed how Andy (like every one of us) grows up and forgets how to see the world from the child's perspective.

Hey, guys, come to think about the age at which we still believed that inanimate objects, like Woody and Buzz, can feel envious and be genuinely upset. At that time, we might recognize that someone is feeling sad and then offer comfort in the way children find comforting. The comfort blanket a child offers, be it a teddy, Sheriff Woody, or a hand-painted Roly Poly Clown, is truly a sincere offer. Call it "egocentric" if you wish, but this should never be confused with the term "selfish."

Fast-forward to adulthood. We learn a great deal as we grow up. Ten or twenty years of hard work it had taken us. That was then. This is now. And we lose the capacity to see a children's world. We can no longer understand a preschool child when we lose the vision from their perspective, after transition to a much sophisticated standpoint.

Buffalo

Most of us (I'm guessing here) have read the stories written by Scottish physician Sir Arthur Conan Dolye. Most of us (still guessing) think that medical doctors must have learned from Sherlock Holmes.

And that is where we go wrong (I'm not guessing any more). Great stories like A Study in Scarlet or The Sign of the Four have never appeared in our curriculum of medical students. Of course they should. A doctor's job is more or less a detective work, piecing together the evidence, poring over observation of every system and the eventual "whodunit" revelation.

In suggesting this, I am making no claim for the prowess of the London-based consulting detective. I couldn't profess to know what Sherlock Holmes have mastered. Yet I firmly believe that this is essential if we are to be good clinicians.

This reminds me of recent encountering a lady with hypertension in my clinic last week, together with medical students. They were supposed to listen and afterward, to respond with wisdom and perspective. After talking about the treatment plan for a while, I observed a rash over my patient's sun-exposed area. "Why don't we have a quick look at the rash and see if it's related to the medication?" I continued as I examined her.

"Doctor, I observed a buffalo hump at her neck," one of my students reminded me when my patient dressed up. "We're taught that such weird fat deposition at the base of the neck indicates Cushing's syndrome, aren't we?"

"Yes," I acknowledged with reluctance, "she did have a buffalo hump. Good observation. But be not beguiled." With this, I went on to tell my students why I didn’t think our patient has the syndrome with prolonged elevation of corticosteroid levels. "Well, there is absolutely no excessive fat over the trunk and face. She stands up from squatting position without difficulty."

Instead of continuing a lecture upon Cushing's syndrome, I paused and asked my patient, with the aplomb of Sherlock Holmes, "May I ask if you used to carry loads of heavy objects over your neck or above your shoulder blades?"

"Oh my, how do you know? I was a farmer."

Good Old Days

There is an unwritten rule that if you want to learn medicine you have to learn by words of mouth. I have come to believe more with every passing year that despite new gadgets like UpToDate, it is still apprenticeship that works for new doctors.

So what can I teach the new interns? They looked helpless indeed. I rose from my chair, and straightened my white coat. "Honestly, I once made a bad mistake during my internship." I tried to correct myself. "Well, I've probably made lots. Yep, but I learned a lot. A clever man learns from his own mistakes, but a wise man learns from others' mistakes."

I couldn't deny it. I get very excited when I think about my intern days. Even now. The memory stays. You could put me back at the hospital where I once worked as a surgical intern fifty years from now, in pitch dark, and I'd still know where I am.

"But off the record," I was asked, "what would you have done in a different manner during your internship if you happened to have a second chance?"

"Very droll," I replied immediately. "I would have kept a diary. I'm pretty sure I'd got lots to write down."

I know very well that memory is not, as many of us think, an accurate transcription of past experience. That's what they say. Memory, I was once told, is a story we tell ourselves about the past, full of distortion, wishful thinking, and unfulfilled dreams.