T.G.I.F. Thank goodness it is Friday! For most of America, Friday signifies the end of the work week. Joy permeates the work place as almost everyone prepares for the weekend. As a physician on call my weekend sentiments are summed up by the phrase "only three more working days until Monday."
Weekends on call can be back achingly busy or mindless dull (less so with Internet access) but the fact is I will eat with, sleep with and carry my beeper to the bathroom for the next seventy two hours. Since I am in a specialty that requires me to be close to the hospital it is difficult to make plans that cannot be dropped at a moments notice.
There was a time in my life when having a beeper and later, when they became available, a cell phone, gave me a feeling of importance and limited freedom. My services were so necessary that I must be accessible twenty-four hours a day. Today beepers and cell phones are common place and there is much less mystic surrounding those who carry them. Now I look forward to times when I am not required to be readily available and I can turn these devices off or leave them at home.
There was also a time when my beeper going off or the phone at home ringing made my stomach lurch with the thought that some disaster required my attention. Now I am more calm, a veteran of twenty years of on-call nights, weekends and holidays. I still reach a point, especially when I am tired that the sound of my beeper causes a wave a nausea to come over me. I may be pleasantly surprised to look at the message and find something that can be cured with a phone call.
In twenty plus years of private practice have also learned to look around, seeing the plight of others. The nursing staff, ward secretaries and house keeping are right there with me. With much less freedom than I, they are required to remain in the hospital at their post for their entire shift while I get to leave when the task is done. Even outside the hospital a number of stores are now open twenty four hours a day requiring clerks to staff them. Many in the service sector such as police and fire personnel work nights and weekends. What about those women and men in Iraq? I bet they would love to get some time off on Monday.
With three more working days until Monday, I am lucky to have a job which is rarely routine and frequently intellectually stimulating. There will also be at least one and probably several very grateful people who will need my services this weekend. Next weekend? Someone else will have the beeper and I will be thankful for the time for fun.
Friday, August 3, 2007
Thursday, August 2, 2007
Art and science
Several years ago to begin a remodeling project in our kitchen, I called an electrician to make sure that the existing wiring would be adequate for our needs. Our house was about thirty years old and an addition had been built on prior to our ownership. After a thorough inspection the electrician took us around the house showing us areas that were problems along with his proposal for fixing them.
Once the electrician had completed his presentation, my spouse began to tell him that we had a different plan. I began to laugh. This experience was so much like practicing medicine that I could not believe it. "Now, I don't do electricity," I said to the electrician. "People come to me for problems with their health." Yet I was struck by the similarity of situations. I knew from experience that I would either pay this man to do what he deemed best or get another electrician. He was there as the expert in his field. In hiring him we were asking him to assume some of the responsibility for the safety of the electricity in our home. Mistakes in his craftsmanship could result in a power outage in the least and a major house fire at the worst.
Patients often come to my office with a predetermine plan for treatment. What they would like to do is based on their symptoms, reading and/or talking with friends and their desired outcome. I listen to what they have to say and the process they have been through to come to those conclusions. This often helps me in making a diagnosis and planning treatment. At that point I often ask the patient if she is willing to trust the me to be the doctor. In most instances the patient will give me a chance.
However this is where the similarity between electrician and physician ends. Electricity is a constant. It behaves in a predictable way. Patients are not carbon copies of each other which happens to be one of my favorite aspects of medicine. Even a "text book case" is going to be different from what is in the textbook because each patient is an individual. I explain this to patients by trying to list for them as many possible outcomes as I can before they begin treatment. The some of the art of medicine is to do this in such a way that the patient will trust that his will be the best possible outcome. In some part of the success of a treatment is derived from the patient's expectations. I always include the fact that even if the risk of a complication is one in a million, if they have that complication it really doesn't matter what happened to the other 999,999 people.
Yes, medicine is a science. More and more with each new test or treatment physicians can be technicians. In the skill that comes with increased knowledge in the science of medicine I pray that as physicians we will continue to excel in the art of medicine as well.
Once the electrician had completed his presentation, my spouse began to tell him that we had a different plan. I began to laugh. This experience was so much like practicing medicine that I could not believe it. "Now, I don't do electricity," I said to the electrician. "People come to me for problems with their health." Yet I was struck by the similarity of situations. I knew from experience that I would either pay this man to do what he deemed best or get another electrician. He was there as the expert in his field. In hiring him we were asking him to assume some of the responsibility for the safety of the electricity in our home. Mistakes in his craftsmanship could result in a power outage in the least and a major house fire at the worst.
Patients often come to my office with a predetermine plan for treatment. What they would like to do is based on their symptoms, reading and/or talking with friends and their desired outcome. I listen to what they have to say and the process they have been through to come to those conclusions. This often helps me in making a diagnosis and planning treatment. At that point I often ask the patient if she is willing to trust the me to be the doctor. In most instances the patient will give me a chance.
However this is where the similarity between electrician and physician ends. Electricity is a constant. It behaves in a predictable way. Patients are not carbon copies of each other which happens to be one of my favorite aspects of medicine. Even a "text book case" is going to be different from what is in the textbook because each patient is an individual. I explain this to patients by trying to list for them as many possible outcomes as I can before they begin treatment. The some of the art of medicine is to do this in such a way that the patient will trust that his will be the best possible outcome. In some part of the success of a treatment is derived from the patient's expectations. I always include the fact that even if the risk of a complication is one in a million, if they have that complication it really doesn't matter what happened to the other 999,999 people.
Yes, medicine is a science. More and more with each new test or treatment physicians can be technicians. In the skill that comes with increased knowledge in the science of medicine I pray that as physicians we will continue to excel in the art of medicine as well.
Wednesday, August 1, 2007
Knowing the question
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Knowing the questions
To make a diagnosis a physician needs to know how to obtain the appropriate information. This information often comes from listening to the patient. Occasionally it is acquired in the process of examining the patient. Less often the answer lies in the tests that are ordered, blood work, x-rays and the like. Sometimes the most important information comes when the physician asks the patient questions. These questions maybe about symptoms the patient is experiencing but at times there is information that is more important than symptoms. Here is an illustration.
One of the most brilliant physicians I have ever worked with is Dr. Lane Gentry. At the time I was a medical student Dr. Gentry was practicing infectious disease. Later he became Chair of the Department Medicine and Chief of Staff at the primary teaching hospital affiliated with Well Known Medical School. For me Dr. Gentry was an outstanding role model. I learned more about practicing medicine in the 30 days that I spend on Dr. Gentry's service than in the previous three years of my training. Dr. Gentry was a master at knowing the right question to ask.
Each Friday in our city of three million, a city wide infectious disease conference was held. The conference was attended by physicians from all over the city and represented the most difficult infectious disease cases of the past week. The auditorium was always packed.
The ultimate stump the professor routine was the format. If the patient was well enough to attend he or she would be on stage where a resident physician would present the events leading up to the diagnosis. At this conference as well as working with patients in the County Hospital I got my first up close look at diseases as tuberculosis, bacterial meningitis, hepatitis, and HIV/AIDS, which then did not have a name since the cause had not yet been identified.
I will never forget the conference that began with a elderly, tall, thin, African American gentleman sitting on stage. He looked as if he would like to smile but was too intimidated by the fact that about a hundred and fifty men and women in white coats were staring at him. He was well dressed in coat and tie appearing as if he was on his way downtown to a desk job in one of the high rise office complexes.
The resident physician began by introducing the patient to us as Mr. DW (initials or chart numbers only were used). The patient was brought to the doctor by his family who thought he needed medical care. When ask directly the patient had no complaints. The family's complaint was the Mr. DW had begun to "look older." When ask to be more specific his daughter said that his ears were wrinkling and so was his forehead. This seemed to happen overnight. Over the next several weeks many tests had been done and the diagnosis was obtained.
Now it was up to the five infectious disease doctors seated on the front row who had never met the patient to come up with the diagnosis. Sometimes the questioning could go on for an hour as each took their turn. Dr. Gentry immediately raised his hand. "May I ask the patient a question?" Dr. Gentry ask the resident.
"Certainly," came the resident's reply.
"Sir, do you ever eat armadillos?" Dr. Gentry's asked.
Immediately Mr. DW replied, "Everyone I can catch!" his smile finally breaking through.
"Mr. DW has cutaneous leprosy," Dr. Gentry stated to the audience. "The test that made the diagnosis was a skin biopsy of his ear." Sure enough, the microscopic slide was then projected on the screen, revealing the bacteria found on the skin biopsy. Mr. DW had begun his treatment with the appropriate antibiotics and the wrinkled skin would begin to disappear.
Knowing the questions. The answer is easier to find once the right question is asked.
One of the most brilliant physicians I have ever worked with is Dr. Lane Gentry. At the time I was a medical student Dr. Gentry was practicing infectious disease. Later he became Chair of the Department Medicine and Chief of Staff at the primary teaching hospital affiliated with Well Known Medical School. For me Dr. Gentry was an outstanding role model. I learned more about practicing medicine in the 30 days that I spend on Dr. Gentry's service than in the previous three years of my training. Dr. Gentry was a master at knowing the right question to ask.
Each Friday in our city of three million, a city wide infectious disease conference was held. The conference was attended by physicians from all over the city and represented the most difficult infectious disease cases of the past week. The auditorium was always packed.
The ultimate stump the professor routine was the format. If the patient was well enough to attend he or she would be on stage where a resident physician would present the events leading up to the diagnosis. At this conference as well as working with patients in the County Hospital I got my first up close look at diseases as tuberculosis, bacterial meningitis, hepatitis, and HIV/AIDS, which then did not have a name since the cause had not yet been identified.
I will never forget the conference that began with a elderly, tall, thin, African American gentleman sitting on stage. He looked as if he would like to smile but was too intimidated by the fact that about a hundred and fifty men and women in white coats were staring at him. He was well dressed in coat and tie appearing as if he was on his way downtown to a desk job in one of the high rise office complexes.
The resident physician began by introducing the patient to us as Mr. DW (initials or chart numbers only were used). The patient was brought to the doctor by his family who thought he needed medical care. When ask directly the patient had no complaints. The family's complaint was the Mr. DW had begun to "look older." When ask to be more specific his daughter said that his ears were wrinkling and so was his forehead. This seemed to happen overnight. Over the next several weeks many tests had been done and the diagnosis was obtained.
Now it was up to the five infectious disease doctors seated on the front row who had never met the patient to come up with the diagnosis. Sometimes the questioning could go on for an hour as each took their turn. Dr. Gentry immediately raised his hand. "May I ask the patient a question?" Dr. Gentry ask the resident.
"Certainly," came the resident's reply.
"Sir, do you ever eat armadillos?" Dr. Gentry's asked.
Immediately Mr. DW replied, "Everyone I can catch!" his smile finally breaking through.
"Mr. DW has cutaneous leprosy," Dr. Gentry stated to the audience. "The test that made the diagnosis was a skin biopsy of his ear." Sure enough, the microscopic slide was then projected on the screen, revealing the bacteria found on the skin biopsy. Mr. DW had begun his treatment with the appropriate antibiotics and the wrinkled skin would begin to disappear.
Knowing the questions. The answer is easier to find once the right question is asked.
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