September 29, 2008 – 11:19 PM
SACRAMENTO, CA - An area man was hospitalized yesterday after pharmacist Niles Kildare mistakenly switched his usual blood pressure medication with one that is culturally incompatible. This marks the third time this month that the medical profession has harmed a patient because of a cultural error and has raised the need for improved cultural training among medical professionals. According to a recent study published in the Aug 2008 edition of JAMA, patients were only asked about their ethnicity during five percent of doctor visits and they were asked about their religion less than 1 percent of the time. Furthermore, in instances when physicians do correctly diagnose a patient's culture, they continue to labor under an average of 3.4 cultural misconceptions. According to a spokesperson for the LCME, attendance at a minimum of 12 religious ceremonies and five cultural festivals may soon become a medical school graduation requirement. Currently, only 17 percent U.S. medical schools require their students to be members of a culture prior to graduation.
September 17, 2008 – 3:14 PM
We had a grand rounds lecture about suicide prevention in the Southeast Asian population. After gnawing at my fingernails during one of the most tedious hours I have endured of residency to date, the speaker graciously spent the last 60 seconds or so of her suicide prevention talk giving us clinicians some actual guidance on how to prevent suicide.
Relevant slide #1 - up 50% of people who successfully commit suicide have seen a doctor within the past 1 week
Relevant slide #2 - ask your patients about whether they are suicidal
the end
The scientifically astute clinicians out there will note a logical leap between slides #1 and #2 that olympic medalist Andrei Silnov wouldn't have been able to make. We have: if A then B, if B then C. A therefore C. WRONG!
I have yet to see any data to suggest that asking patients about suicidal thoughts leads to suicide prevention. I have yet to see any data to suggest that treatment for depression leads to fewer suicides. If anything, it seems that the opposite may be true. If I am wrong about this, please educate me. To echo Cuba Gooding Jr.'s character in Jerry McGuire, "Show me the data!"
Is suicide preventable? Perhaps. But please find out before subjecting me to an hour long lecture on suicide prevention.
September 14, 2008 – 11:36 AM
We've all heard a lot about how governor of Alaska Sarah Palin said, "Thanks but no thanks" to a congressional earmark set aside to help Alaskans build a "bridge to nowhere." I heard her speak these words at the Republican convention and I assumed she was using hyperbole - employing the euphemism "bridge to nowhere" to refer generally to her so-called record of reform and of opposing wasteful government spending. We've now learned that Palin was actually in favor of this bridge before she opposed it . She admitted as much in her interview with Charles Gibson last week. She only decided that she was opposed to once it became clear that Alaskans would have to pay for it themselves.
What baffles me about this is not that she lied. While this particular lie is somewhat more egregious than many of the lies we're used to, distortions of the truth are to be expected during a presidential campaign; it's par for the course. What baffles me is that, even in her admission that she once supported this project, she continues to refer to it as a "bridge to nowhere." And, in all my searching, I haven't been able to find what two places this bridge was actually supposed to connect. I mean, it had to have gone somewhere. On the other hand, if you live in Alaska you're already pretty much in the middle of nowhere anyway. Inasmuch as this is the case, every bridge in Alaska leads from nowhere to nowhere. But, if we accept, for the moment, the claim that everywhere is somewhere, it is more reasonable to assume that the bridge in question actually would have connected somewhere with somewhere else. Now, if the Republicans believed the American people have any intelligence, they would publicize this. The story would change to: ok, she supported it, but the bridge actually did go somewhere. Somebody in Alaska had wanted this bridge to be built. Even if it was only a small family of lumberjacks who wanted a quick route to their local Denny's - at least there would be some logic behind it. But, the sad truth is that the Republic party has so little respect for the ordinary citizen's powers of reasoning that they believe we will simply accept both the fact that Sarah Palin had supported a completely illogical project and, at the same time, that she is a reformer. They have apparently made the calculation that it would be more damaging for Sarah Palin to have anything on her record that could allow one to label her a 'liberal' than to have something in her record that would allow us to label her a complete moron.
September 10, 2008 – 7:47 PM
Well, if I'm your doctor, chances are probably not. This isn't because my patients are not comical or stupid - they often are. But rather, it's because with all the demands that residency puts on you there is just no frickin' time! To laugh at someone takes extra planning and energy that can much better be spent catching up on discharge summaries, taking in a sporting event, sleeping or laughing at ER Stories's patients. But, for me, the answer is 'no,' I never laugh at my patients. Neither do I tend to engage in other unnecessary and time-consuming activities such as empathizing with my patients. There is generally more than enough patient-related work to keep us residents occupied without piling on these extra tasks.
However, a recent CNN article reported that 17 of doctors had admitted to having made fun of a patient while he or she was under general anesthesia. Such behavior is described by this article as "unprofessional." It continues to irk me to no end that stupid shit like this still gets media coverage. If you want to call this kind of behavior unprofessional, that's fine by me. But do not then write about unprofessional behavior as if you're writing about something meaningful.
The term unprofessional, as it relates to medicine, is currently used as a catch-all term for any behavior that we don't like to see doctors engaging in. Anyone who uses it is invoking his own set of values, biases and opinions which may or may not have any bearing on the topic of discussion. I do think there are certain behaviors we, as a society are entitled to expect from doctors in exchange for granting them a license to practice medicine. For example, we are entitled to expect them to respect confidentiality, to provide medical care based on the most current evidence, to disclose all financial relationship when giving talks on disease management etc. Are we entitled to expect that our doctor won't laugh at us while giving us excellent care? No. Most doctors won't laugh at you - for the reasons I mentioned above. But I find myself under no obligation to refrain from holding my side and bending over in a hearty guffaw over whatever mess you've gotten yourself into. I hope you don't take offense. I am, after all, very sincerely trying to help.
September 5, 2008 – 9:01 AM
A car rear window shade caught my eye in the little shop next to our hospital cafeteria. "Hello sir, may I help you?" The African American lady who ran the shop looked to be in her late fifties. She greeted me with a warm, friendly smile.
"Oh, no thanks," I replied - as it was really a shade for my front windshield I was after. "I'm just looking."
"Ok. Well, you let me know if you have any questions. And have a blessed day."
I thanked her, hoping she felt my appreciation for waking me from my usual 6am state of morning-zombie into a warmer, more colorful world. I imagined that maybe she had a husband. Maybe three or four children and perhaps even a few grandchildren. I imagined her children all coming to visit her on Thanksgiving day, all pitching in to do the dishes, telling stories and laughing late into the evening.
She turned to finish a previous conversation she had been having with one of the cashiers. "Well, I don't know how you just stand by and let something like that happen. I mean, if we still have the bomb - and I was informed we do - and it was up to me, the Middle East would be nothing but a memory. It'd be nothing but sand."
"That's right, just take the whole damn country out," her cashier chimed in.
"Like Sodom and Gomorrah in the bible," she went on. "You gotta just take out the whole God damn country."
I wasn't sure exactly which country she was referring to. Perhaps she believed the Middle East to be its own soverign nation. Such a nation is probably evil, probably wants to destroy the U.S. and probably has Osama Bin Laden is its president. It was beginning to hurt my sould to think about it any more deeply so I sighed, half closed my eyes and continued to shuffle through the day in zombie mode.
September 2, 2008 – 12:01 AM
We had a patient on the unit with a murmur last week.
"I want you guys all to go listen to his murmur," our attending told us on rounds. "Then tomorrow, we'll talk about it and decide what kind of murmur he has."
This patient had already had a transthroacic echocardiogram showing a narrowing of the aortic valve. But, we all dutifully listened anyway - our prior knowledge of what the patient had helping us to form a meaningful story about the faint swishing sounds we were hearing over his chest. It's probably a better characterization of what we were actually doing to say that, rather than listening to his heart, we were placing our stethoscopes on the patient's chest and recalling what aortic stenosis is supposed to sound like.
We are greeted by critical care attending the next day. "So what did you hear?"
"I heard a crecendo-decrecendo murmur that was loudest over the right, second intercostal space, radiating towards the neck." If my response sounded as if I was quoting the textbook, it was because I was.
"Can you draw it for me?" I copied the diagram illustrating aortic stenosis from my physical exam text. We talked for several more minutes about the subtle findings one can use to assess the severity of disease in someone's aortic valve using only a stethoscope. It was an underwhelming discussion.
When there is a much more sophisticated method of assessing someone's heart valves that is relatively cheap and easy, why do we continue to care what we find using the stethoscope? I'm beginning to wonder why I still carry the damn thing around my neck all day! Why would you bother trying to move a 15 ton pile of dirt with a shovel when you have a bulldozer readily available? Today, there are very few clinical decisions that it is still appropriate to make based solely on what you find using a stethoscope. There are a few conditions for which it continues to be of some use in making diagnoses - asthma, pneumonia or congestive heart failure, for example. But, please don't ask me draw a diagram of someone's heart murmur. I can't imagine any responsible surgeon making the decision to replace a heart valve based on my pencil markings.
