A new paradigm?

A friend of mine once considered going to officer candidate school (OCS). Of course, he didn't realize this was for folks who want a commission in the armed services, and when we let him know, he reconsidered. However, I don't think that OCS is a bad thing. In fact, I think that things like OCS are quite useful sometimes.

One thing that I think medical school is lacking is training student doctors what it means to be a doctor. There is the education and interviewing and a lot of other aspects that go into medical education. However, I think that a lot of medical schools lack training in the professionalism and ethical behavior of being a doctor. Certainly every school teaches medical ethics, but it is in the safe environment of a classroom. It lacks the thing that OCS excels at: put someone in a real situation and watch them squirm.

An intern I was working with was managing a patient in the clinic, and I saw the patient on a sick visit, and one look at this poor patient was enough to admit him to the hospital. It was a judgment call, but one that the intern should have been able to make. Why didn't the intern admit?

I was the admitting resident and had 3 admissions from the clinic. None of the residents or attendings had contacted me to let me know. Two patients were having acute CHF exacerbations. One was an acute asthma exacerbation. After seeing these three patients, I transferred one on the cardiac stepdown unit, and one patient went to the ICU. Why didn't any of their doctors contact me about the acuity of their patients?

I think that medical school needs to teach doctors to make good decisions, because if you don't want to make good decisions, you shouldn't be a doctor. Being a doctor is all about making decisions. You may not make the right calls all the time, but you must continually question your decision making process, and evaluate yourself critically.

And after confronting all of the medical personnel mentioned above, several mentioned their poor decisions based on workload. They were too busy to do the right thing, and they all recognized that there was a right decision and a wrong one, and that they had not made the right call. But it took being confronted about it. I wasn't mean or rude. After all, in some cases, I was a resident questioning an attending. But if I didn't confront these folks, would they have learned?

I had a part time job once where my boss was a former marine. Let me tell you, having a marine for a boss is a mixed blessing. It turned a pretty easy job into a LOT of work. But the job had relatively little direct supervision. If I did a shitty job, no one would really know. But I always did my best.

My boss recognized me in a meeting, and I was completely stupefied. What had I done other than what was expected? And I realize now that what I had done was something quite simple, but something worth recognition. Without any desire for reward or recognition, with no one looking over my shoulder, I had done my best, because if I was going to do something, then it should be done right.

And I was talking to my boss about being a marine, and he told me that they teach marines something simple but profound. A marine should always do the right thing, even when no one is looking, because that is the best way to judge a man. And I agree. I think that if you can very accurately judge the character of a man by what he does when no one is looking, and by what he does when he is under pressure. Does he do what is right or what is easy?

I told my marine boss that I wanted to be a doctor, and he told me that I would be excellent. What did he know about being a doctor, I thought to myself. He told me that excellence is all about being excellent in all things. And if I can do a good job with essentially meaningless work, then how much better I would be at something where I can make a difference.

And I'll tell you right now, when I see students and residents, I let them know that you can know Robbins word for word, but that won't make you a good doctor. You measure a doctor by how he cares for his patients. And when I was a senior resident, the folks I came down hardest on weren't the ignorant, but on the lazy. I have no sympathy for laziness or arrogance. How can you ever look at yourself in the mirror if you don't do what is right when someone's life is in the balance?

If I could teach that to a medical student, just one, then that would be enough to change the world.

Where's your stethoscope?

Nowadays, the new, hot thing is to wear your stethoscope on a belt clip. The ER folks are in love with this, because they typically don't wear lab coats, and the stethoscope can irritate the neck. Moreover, getting that weight off your neck is very relaxing.

What's interesting is that how a doctor carries a stethoscope can say a lot. The way you wear a stethoscope speaks volumes about when you trained. Here are some observations that I have made.

You carry your stethoscope in a doctor's bag: you remember when penicillin was first mass produced. When someone talks about Osler, your reply is, "Osler was an ass." Your day is done and you are likely dead now.

You wear your stethoscope like a tie (your neck between the ear pieces): You speak of the 'good old days' of fee for service, and bemoan Medicare, as you remember the days when it did not exist. The words, "Evidence Based Medicine" make you want to vomit. Still, you try to impart wisdom to the younger generation of physicians who don't know any better. You reminisce of the days when everyone had traditional indemnity insurance, patients did as they were told, and no one thought medical paternalism was bad.

You wear your stethoscope around your neck: You are a new breed of doctor who trained in the HMO/PPO era. This style is the current norm these days. It is a strain on the neck and if your stethoscope is not long enough, it's quite annoying. However, you comfort yourself with the knowledge that medicine is now guided by science and best evidence, and you wear your stethoscope more for decoration, since you have never heard a murmur in your life, and wouldn't know one if it bit you in the ass.

You use a belt clip or keep your stethoscope in a coat pocket: You are trying to be on the cutting edge, the avant garde of stethoscope fashion. But no one is impressed. And everyone secretly laughs at you when you get your scope caught in the arm of a chair or on a door knob.

Of course, I'm joking around, but really, the generation gaps are there. I think it would be really interesting if people started carrying scopes differently. I am all for keeping it in the pocket. Truth be told, our physical diagnostic skills have gone to the dogs, and I no longer see that the stethoscope deserves a place of prominence around the neck.

And by the way, I ruthlessly stole all these pictures with Google searches. Sorry. However, while googling, I did discover there is a whole world of stethoscope fetishes. Apparently, there are some very creative uses for stethoscopes.

Just wanna be loved

This American Life has once again hit a hot button for me, talking about reactive attachment disorder, which is one of the child psych diagnoses that strikes the most horror in me.

The thing that turned me away from child psych is that it is so absolutely horrible. These kids are absolutely destroyed by forces entirely out of their control. I couldn't deal with child psych because for the most part, the pathology wasn't in the children; it was in the parents. Kids aren't born with reactive attachment disorder. It exists because there are awful people and situations out there, and it is actually possible for a child to grow up without love. The consequences are terrifying.

But one commenter wrote about her own work with foster children, and after listening to the radio program, I got a little hope. Maybe these kids do have a chance. But it takes so much dedication, so much work. And it's hard and scary. I'd like to think I could do it, but I couldn't. My basic pathology is that I desperately want to be loved, not the other way around.

Catharsis: all about being dumped

[This post has nothing to do with medicine. If you have had your fill of self-pity, go ahead and skip this one.]

There have been a lot of comments about the dumping post. I came up with it while driving. I carry a voice recorder with me. My exact quote: "If I ever get into a relationship again, and it goes south, I'm going to dump her before she can dump me. I'm never going to be the dumpee again."

For years, I've lived in a self-imposed emotional isolation, content to say that the risk of loving was far too great, and it was better to be alone. This was a pretty stupid decision, but I certainly can see the reasons behind it. The problem is that rather than take steps forward, I've gone backwards.

If you want to know why I'm so vicious about being dumped, I'll provide you with some context. One episode that jumps to mind was in college. It's classic soap opera. Girl dumps me for my best friend who was seeing her behind my back. It should speak volumes that I blamed myself for this entirely, and rather than get angry, I tried to keep a friendship with them. Part of my motivation was that my entire social circle was tied into these two. I wasn't about to make all my friends pick sides. So, we tried to be friends still. It was almost unavoidable. My friend lived in the same apartment building.

Friday night came, and I waited to hear from the grapevine what plans for the night would be. And I waited, and waited. My roommate was out on a date, so I was in my apartment alone. I sat by the phone for a while, then started calling around. Finally, I went up to my friend's apartment. One of his roommates was there. They had all been there, my friends, and they had hung out for a couple hours, and then left for a bar or club. Due to some circumstances I won't go into, I was physically stuck at home. Even if I wanted to follow them, I couldn't.

The most absurd part of all this was that in order to get to my friend's apartment, you had to walk past mine. So all of my friends had walked right past my apartment to my friend's, and then later walked past again. And at no point in time while I was less than 100 feet away did anyone think to call or even knock as they walked by.

I think what hurt most was I couldn't figure out if it was out of spite over this breakup stuff, or out of sheer apathy, that I mattered so very little that it had not even occurred to them to see if I was in. Despite several phone messages on a variety of answering machines, I never got a call back or an apology. When I confronted them, they said they thought I wasn't in. As if I had somewhere better to be.

I was so angry that I was throwing things all night. Some things are surprisingly sturdy! I am not an overtly angry person. Most of my friends have never seen me angry, but that night, I was furious. And which was the better option: was it better to have friends who were so cruel or so utterly thoughtless?

I made a resolution right then. I would learn to be happy on my own, because it was clear to me that I could not trust other people to be there for me. It took me a while, but I burned those bridges and left all those people behind. And looking back now, I can see what a terrible resolution that was, and how so much of my unhappiness with life was self-inflicted. It was as rash a reaction as possible, but not a surprise. They abandoned me.

Just last month, I realized that my life is governed by an utter fear of abandonment. It scares the crap out of me. I made a list of all the horrors of my life, and when I looked down the page, it was all the same: abandoned by family, by friends, by lovers. And so, that one night in college, more than anything else they had done (and let's see, dumped, two-timed, ridiculed, mocked... the list continues), spelled the end of my friendship with them, because they had done the only thing I couldn't forgive.

And I'm trying now to forgive, and to let go of all the emotional torture I've self-inflicted. And that hurts, but what options do I have? All this time, I have burned with furious indignation. But there is no reward in that. There is no comfort. My anger will not change the past, and very likely has made absolutely no difference whatsoever in the lives of the people who have wronged me. I can keep holding onto my anger, but for what purpose?

And so, I've decided it's time to move on, and that means facing all this fury and quenching it. And at least acknowledging it is a start. And as angry as I seem about this one Friday night, it is only a crumb in a life full of being left behind. And as much as I am trying to grow as a person and move on from all this turbulence, I know in my heart one thing: if given the choice, I would rather be the dumper than the dumpee.

The litmus test for good health care

Once when I was a senior resident, I had an intern who was taking real shitty care of one of his patients. He couldn't have cared less about this patient. His notes were sloppy. His management poor. I was cleaning up all kinds of loose ends. Finally, I confronted him.

He hated the patient. He thought that the patient was manipulative and mean-spirited. To say his care for her was dispassionate would be a compliment compared to the job he was actually doing. But hating a patient doesn't give you the right to do a shit job.

"Yes, she's a bitch, but she is someone's mother. And if you took this kind of care of my mother, I would sue you out of spite. And my mother makes this lady look like Mother Teresa."

There are two tests that are quite useful when caring for patients. It becomes very easy to forget that we are treating people and not diseases, because all we see are the diseases, and it's hard to get to know the people. So it's helpful to ask yourself two questions when you feel a little lost in the storm:

(1) Is this the care I would want for my parents? (2) Would my parents be proud of me if they could see what I'm doing?

If you can answer yes to both questions, then you're doing alright. If not, it's time to take a step back.

Flip flop

When ADOPT came out last year, it was pretty much a home run. Many practitioners were advocating changing guidelines to recommend Avandia (rosiglitazone) as initial monotherapy. I was quite vocal in my disagreement. I think metformin has more favorable effects, blah blah.

Now that rosiglitazone's safety has been seriously questioned, everyone is jumping on the 'TZD's suck' band wagon, which is dragging pioglitazone down with it. I find this very amusing because it kind of typifies the trend in US pharmaceuticals.

I could understand the arguments against Vioxx, a drug made for symptom relief and not much else. Natrecor was disappointing, but it had filled a nonexistent hole anyway. But this Avandia stuff is ridiculous. You can't tell me that optimal glycemic control does not have benefits. We have modeled ALL of glycemic therapy on this idea, that microvascular disease is the consequence of hyperglycemia.

And none of this talk answers a quite serious and obvious question about Avandia. Is Avandia doing something or not doing something? By that I mean is the risk caused by the drug itself or is the increase in heart attacks the same as untreated diabetes? If it's simply the risk of untreated diabetes, well then I'll slap some metformin on top and call it a day. But if the drug is causing heart attacks, that's a different story.

I'm willing to concede cardiovascular disease, but keep in mind that there are a lot of complications of diabetes. Choosing between them is like trading bananas for pears. Is it better to have heart disease or kidney failure? Is it better to be blind or a CHF patient?

I don't like TZD's and I've never been a big fan, but I can't argue with the fact that they work, and work well, and probably are one of the best oral diabetes medications. Since this all came out, I haven't written any scripts, and thankfully I've always preferred pioglitazone so I can at least hedge my bets until we figure out if this is a class effect. But I'd be hard-pressed to say to someone that Avandia was bad for them.