Last spring, I took an online learning module developed by the pediatric department designed to test my knowledge of vaccines. For my participation in this experimental project I received a Starbucks gift card. Last month, I took a survey designed to evaluate some of our internal clinic procedures. For my participation I received…a Starbucks gift card. The thing is, I don’t actually drink coffee!
Most of you reading this won’t understand what it’s like for a non-coffee drinker like myself. Coffee is so pervasive in our society, soon it will be coming out of our faucets! I replay the following scene at least a few times every week.
Colleague #1: Hey, I’m going to the cafeteria to get some coffee, anyone want some?”
Colleague #2: Sure, I’ll join you.
Colleague #3,4,5…17: Us too!
(Everyone turns to me)
Colleagues 1-17 (simultaneously): James?
Me: No, no thanks. No coffee for me.
Colleague #1: You sure?
Me: Yes, I’m sure.
Colleagues 1-17: (exchange confused looks and murmur to each other) Really?
Me: Yes! Yes, I’m absolutely sure. Please, read my lips…no coffee for me. Really!
Coffee is everywhere in our society. Every morning, someone in my vicinity is either brewing it or buying it or grinding it, or french pressing it…and I am constantly having to refuse offers of coffee. Pretty soon, I’m going to start wearing a sign on my head that reads, “To you generous offer of coffee, I politely decline,” and save everyone the trouble.
I do actually drink it sometimes. Just not first thing in the morning. It makes me nauseous, jittery and have to pee when I start the day with it. But, back to my original point, couldn’t the ‘thank you’s’ for the various research projects I have so selflessly contributed to be a gift card from some other, non-coffee specializing establishment? Why not an iTunes gift card, or a coupon for a free lap dance at Club Ecstasy? (Not that I’ve ever been there…just sayin’) Or better yet, the gift could simply be a syringe filled with dopamine that I could inject directly into my brain. That would be cool.
I’m taking ABFM (American Board of Family Medicine) exam on July 19th. Will passing this exam make me a competent family physician? Is it possible to be incompetent and still pass the boards?
The question of what makes any doctor “competent” has plagued me for a long time. Before starting medical school, I was in awe of doctors. How can they possibly know and keep at their finger tips all of the facts and skills they need in order to provide good care and avoid mistakes? I had no idea how doctors obtain this wealth of knowledge and skills. But I assumed that if I was a good student, passed all my exams and all my rotations and eventually became licensed and board certified, I surely must come out of that process as a competent, error-free physician. I mean, we trust the various medical boards to only license and certify doctors who are competent, don’t we?
But, in truth, in order to pass any exam or rotation, one only needs to know most of the critically important things, never all of them. In other words, passing grades are always lower than 100%. But, presumably, 100% of what we’re being tested on is important. One could be a doctor who scored 99% on all her exams and inadvertently let a patient die because she ignored a PE (pulmonary embolus). Maybe she somehow made it through her training without ever learning about PE and so got every other question right but that one. Is an otherwise knowledgeable doctor who ignores a known PE incompetent? Most of us would say, ‘yes.’
Althought it doesn’t currently exist and almost certainly never will, I continue to hold onto the idea that each specialty should have a syllabus. There should be a minimum fund of knowledge which, once you’ve mastered it, you can declare yourself competent. A family medicine syllabus, for example, would have a section on PE. It turns out that there is such a thing for ACLS (advanced cardiac life support). Providers need to score 100% on the practical part of the ACLS exam. Once they’ve mastered that, they’re done and can be highly confident in their competence as an ACLS provider. But, as a doctor, you just never know.
Getting called into the program director’s office is almost never a good thing. I had received a page from Dr. Mann earlier in the day asking if I had time to meet. The answer, of course, was ‘no’ but we had a mutual understanding that I’d find a way to make time. Despite his ebullient charm, outstanding interpersonal skills and overall casual demeanor, Dr. Mann stands 6’4″ and can be an imposing figure.
“You’re probably wondering why I asked you here,” Dr. Mann smiled and gestured toward the chair in which I promptly sat. He was correct in that I did not know the exact reason for my summons. I wondered which of my many transgressions it was over the past month that had come to our program director’s attention. I feared some more than others. “I just wanted to give you some feedback,” he continued. I already didn’t like where this was going. ‘Feedback,’ in this setting, translates to ‘made aware of a situation in which you fucked up.’ I could be assured, at least, that I wasn’t there to be given ‘constructive criticism’ which translates to, ‘made aware of a situation in which you fucked up royally.’ He continued. “Maggie, our psychology intern, came to me the other day after her standardized patient session with you. She shared with me that, during your feedback session with her, she got the impression that you were looking up her skirt.”
This I had absolutely not seen coming. “Looking up her skirt?” I repeated dumbly.
“She felt like you were distracted and not paying attention to the feedback she was giving you. She felt that even when she crossed her legs and shifted to the side, you were still not listening.” This was absolutely true, of course. I didn’t know Maggie well enough to definitively classify her as a ‘bimbo,’ but her “feedback” had certainly been less than enlightening. That glimpse of her underwear had been the only thing that had made the afternoon worthwhile.
“Well, gosh Dr. Mann. I’m sorry she got that impression. I certainly wasn’t aware of looking up her skirt, or seeing anything that I wasn’t supposed to see. Also…I’m sorry, who’s Maggie again?”
We discussed the situation for about 15 minutes, me all the while breathing an internal sigh of relief that this was the reason for the meeting and not something more egregious. I agreed to meet with Maggie and apologize for making her feel uncomfortable. I hoped she would be wearing the same outfit as last time.
She tapped her pen on a legal pad, briefly stopped and motioned for me to take the seat opposite. Maggie was a psychology intern. She was about 25, tall and wore her blond hair long and straight. She was trim with a nice figure; she almost certainly went to the gym on a regular basis. Today she wore high heels and a black suit jacket underneath which was a sheer white blouse. She sat with her legs crossed. Her matching black skirt came down to about the mid thigh.
At the conclusion of the standardized patient interview, Maggie’s job was to review the video footage with the resident and give him or her feedback on how he or she handled the actor who had been pretending to be a depressed patient. Maggie looked at me through her dark-framed glasses. I wondered whether or not they contained prescription lenses. “So, how do you think you did with this patient encounter?” She sat about 3 feet away, facing me with her legs crossed. Her long, white legs seemed to go on forever. I pondered this while allowing her to induce me to manufacture some feedback on my performance. Feedback on one’s performance within a patient encounter, whether real or simulated, is entirely subjective and largely bullshit. As far as I’m concerned, an encounter with a patient is either successful or unsuccessful. It is successful if a plan of action is developed that everyone is on board with. Sometimes a plan is developed, but only partially implement or sometimes the plan represents a compromise between what the doctor recommends and what the patient is willing to do. In these cases I would call the encounter partially successful. Better doctors are the ones who facilitate the most successful patient encounters. I pondered this as Maggie leaned forward, uncrossed her legs and said something about “eye contact” and “empathy.”
“What do you think you could improve upon for next time?” She leaned back as she asked me this and I took note that there was just enough separation between her knees at this angle to make visible the shiny, white panties she was wearing. She crossed her legs again as I said something about being “patient-focused” and asking open ended questions.
There was nothing noteworthy about the rest of our exchange and I left the interview hoping to get “feedback” from Maggie again sometime.
NBC will be airing a new reality show set in Cook County prison in which investigators probe innmates for information. A brief glimpse of prison life reminded of my former job as in OBGYN resident. There’s a very real sense in which OBGYN, and most other surgical, residents are actually less free than prisoners. I think Cook County innmates have at least as much control over their day to day activities as I used to. Of course, they can’t quit prison the way I quit my former residency program. Let’s put it to a vote: assuming you would be finnancially set by the end without having to work another day in your life, would you rather spend 5 years in prison or 5 years in a surgical residency?
Just writing a few lines as I wait for Windows 7 to download. I do have a new post planned. In the spirit of the holidays, the topic will be empathy and what the concept is completely irrelevant to medicine. I’ll have it up by Christmas Eve.
The 45 year old man who met my gaze as I walked into the exam room smiled and, at least on first glance, appeared to be relatively healthy. When there is a patient on your schedule listed as “routine health maintenance exam,” it’s hard to know what to expect. Immediately upon entering, however, you can often gauge about how long your visit is going to take. If it’s a 22 year old female who’s not obese and looks pretty normal, then you can expect to do a pap smear, some contraceptive counseling – done. If it’s an 85 year old man in a power chair who’s here with his caregiver and sporting a bulge under his shirt suggestive of a nephrostomy tube, you can expect to be running behind for the rest of the day.
“Hello, Mr. Brazil, I’m Dr. Logan,” I offered my hand in greeting. “This is one of our medical students who is working with me today.”
“Hi!” Jill smiled brightly and waved.
“Um,” Mr. Brazil eyed the attractive 24 year old medical student uneasily, “Would it be ok if I just talked to you today?”
“Sure, no problem at all.” I shewed Jill out of the room. “What can I do for you today?”
“Well, I’ve been noticing over the past several months that my penis has been getting more and more crooked.”
“How do you mean?” I asked.
At that point, the patient lowered his pants to reveal a circumcised penis that was normal in every way except that it made a nearly 90 degree turn midway through and pointed to the patient’s right.
After a bit of research and after talking it over with my supervisor, I went back to see the patient.
“I’m going to give you a referral to urology. There may be some treatment options available but, if none of them are helpful, the definitive management for this condition is surgery to release some of the connective tissue surrounding your penis.”
“Surgery?” The patient appeared to turn a light shade of green at the thought of his penis being flayed open and I can’t say I blamed him. “Is there anything else I can do in the meantime?”
“Well,” I mused, “Are you right or left handed?”
“I thought so. I would say, in the meantime, try masturbating with your left hand. See if things improve. Either way, I’ll go ahead and put in the urology referral.”
I must confess, I haven’t looked at the literature on this – not even sure if there is any. Would any urologists who may read this care to comment on whether there is an association between Peyronie’s disease and which hand a patient masturbates with? Could be a good research project.
For, no particular reason, I was reminded of House of God today. Why do people like that book so much? I feel it’s less insightful than people give it credit for. I read about 2/3 of it five or ten years ago.
“The patient is the one with the disease.” That’s great. I was never worried that I had any disease. My problem, as a resident, is that my patients have diseases which I don’t know how to treat.
“The first thing to do in a crisis is, take your own pulse.” 180. Great, now what?
I will eventually write my own memoir reflecting on my residency years. Maybe with this blog, I can generate some buzz around its release. Plan for it to come out somewhere around 2018.
Mr Paul Lewis’s elbow had been swollen for the past month when he fell backward and landed on it while walking his dog. Multiple joint aspirations hadn’t shown any evidence of infection or any crystals to suggest he had gout. What they did show was blood. He had lots of blood in that joint and a subsequent MRI showing what the radiologist called “extensively destructive arthropathy,” which means that he had all kinds of badness going on inside that elbow. As part of the work-up, our attending suggested we get a rheumatoid factor.
Seriously? A rheumatoid factor? In a patient with an acute problem in a single joint following a traumatic event? And if the rheumatoid factor is positive, we’re going to do what exactly – start him on some NSAID’s and possibly methotrexate and hope he gets better?
The doctor in the example above is double boarded in internal medicine and neurology and was covering our inpatient service for the week. He really is quite knowledgeable. He’s the guy that you want taking care of you if you have diabetes concurrent with poorly controlled seizure disorder. Bone and joint issues…not so much his thing.
I struggle on a daily basis to delineate those facts that I should absolutely know in order to consider myself a competent family physician from those facts which I absolutely do not need to know – to figure out during which lectures I need to perk up and during which lectures I can plug my ears and yell, “la la la la la.” This is quite a bit more difficult than one would think. Nearly everything written in every medical textbook or journal from any specialty is potentially relevant to family medicine. But, even the very best family docs are only familiar with a small portion of this information. In fact, those in our field who have attained the highest levels of prestige and stature (program directors, department chairs, etc) often are the most actively involved in research and therefore have only mastered a relatively smaller portion of medicine as they’ve had to devote more time to learning fewer topics, albeit in greater detail.
So, is the guy who thinks you need to get a rheumatoid factor on someone with an obvious hemarthrosis competent? Every physician has gaps in his or her knowledge. If I graduate from residency with as much knowledge of psychiatry as our obstetrically trained faculty and as much knowledge OB as our sports medicine faculty and as much knowledge pediatrics as the guy who only does adult inpatient medicine, will I be competent? I certainly hope so, because there isn’t a doctor alive who knows as much OB as an OBGYN and as much psych as a psychiatrist and as much peds as a pediatrician and as much about your teeth as a dentist etc. Yet, in family medicen, we’re supposed to know about all of these things. The question is, how much? Where can we stop? Since the very start of my medical career I have been searching for this minimum standard for what it means to be competent. Does passing your boards make you competent? Nah, I think there are plenty of incompetent physicians who’ve managed to pass their boards. The only standard I’ve found so far is that you are competent until you start doing too many things that embarrass your colleagues. And that’s no kind of standard.