Month: May 2012

Medical Linguistics Failure


    I have a problem with any medical conversation that utilizes the term “Failure” in it.

Acute Renal Failure
Hepatic Failure
Congestive Heart Failure
Failure to thrive ( A personal favorite)
Respiratory Failure
Premature Ovarian Failure
(Name your body part) …Failure.

As an internist where most of my patients have chronic conditions, I deal with many of these “failures” daily. I usually have a pretty good grip on handling the medical aspect of such conditions. It’s the psychological component of such a diagnosis and the counseling necessary, that’s harder.

In my efforts to be an empathetic physician, I’ve likened the experience to as follows.

Let’s say I really like my car, but I don’t know much about how it works. The car starts breaking down for a variety of reasons (partly my fault, which I feel terrible about). Its slower, less fuel efficient, makes all kinds of weird noises, leaks random fluids and generally just doesn’t look as good as it used to. So I take it to my trusted mechanic who after extensive work up tells me I have Name your vital auto part Failure. He offers me this prognosis. Instead of maybe 20 years, the car will last only about another 10 years if I’m lucky. And in those 10 years, I can expect frequent mechanic trips, and I may not have access to that car for weeks at a time. I can expect to try a lot of fixes, some of them quite expensive with questionable efficacy. It’s also our only car, and my family relies on this car for anything and everything.

This would be really upsetting, especially when I connect the dots and come to the conclusion that my car is basically dying.

Patients know what vital organs are, and the term “Failure” implies its demise. Every week, I see patients, anxious and upset about these diagnosis mentioned in passing during hospitalization, by specialists or anyone else with an opinion. So in addition to managing the actual conditions, I have to do psychological damage control by trying to put a positive spin on the situation.

Thank goodness, we are now referring to acute renal failure as acute kidney injury. Besides being a more medically accurate term, it’s so much easier to explain to patients. They are less likely to ask about dialysis now and more likely to ask what injured their kidneys and what they can do to prevent it. 

I move to abolish the term “Failure” from all medical terminology.
It’s medical hyperbole that is unnecessary and frankly makes my job a lot harder! 🙂

 

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Shared decision making with patients

    There’s nothing better than sitting down with a patient, going though an entire visit, and  collaborating on a well thought out plan that meets everyone’s expectations. Shared decision making is a wonderful and necessary concept in modern patient care. Paternalistic attitudes are fading away in the medical community as the next generations of doctors continue to get educated on how to manage patients who are very knowledgeable and yearn to be active participants in their care.

    But as patients become more involved in the decision making process, differences in opinion become more prominent. Although these differences can be overcome through open discussion and trust, it is a challenge that is occurring with regularity. In this era of short pressured visits, it’s hard to have long conversations to help meet the patient in the middle when there is a difference in opinion. Litigation concerns also influences decision making immensely, and when there is a debate about whether “to test,” or “not to test,” we might be inclined to align our opinions more towards what a patient wants.
     When a patient adamantly wants something done, and I rationally disagree, it can be a disheartening experience. I reflect on how I’ve spent years studying, training and practicing. I think about how I’ve spent years, not just memorizing facts, but cultivating clinical acumen that integrates multiple data points to compute probabilities of disease states and figuring out likelihood ratios of different tests or medicines and whether the benefits greatly outweigh potential harms and costs. And I have to do this within seconds to minutes in my head, while factoring in patient preference and medico-legal concerns.  I do this juggling act countless times a day, and when I’m wrong it hurts. It hurts my ego a little bit. But it hurts more because you always want what’s best for the patient.
   I’m sure we all have stories of things we regretted ordering for our patients. I can think of several instances of how I acquiesced to a patient’s request that resulted in poor outcomes. Antibiotics that I didn’t want to give, leading to C-Diff colitis, imaging with incidental findings that lead to unnecessary worry, procedures and complications are just a few examples. I can also think of many instances where patients have come to me with positive test results or better outcomes from things I was reluctant to do.
    Whether you are for or against shared decision making, it is here to stay. Patients want to have to more say in their care and that’s a wonderful thing. Involved patients will always do better than detached ones. The modern physician will need a balanced temperament to handle the ups and downs of this two way relationship. Fortunately my ego is just big enough that I return to work every day smiling, feeling good about all my  decisions.  But I do keep my ego in check, mainly by taking some Tums tablets. I’ve realized my heartburn isn’t caused by the coffee I drink, but all the pride I’m willing to swallow and the large heaping servings of humble pie medicine serves me with regularity. 

A patient’s first name.

I often debate whether I should be calling patients by their first name or last name. The gregarious part of me that wants to create a personal family atmosphere thinks first names are better. The professional, respectful part of me sticks to using Mr. or Mrs. The age of the patient also affects my decision. I’m 34, and will not hesitate to use first names with patients younger than me. With a rapidly aging population, most of my patients are much older, and formal salutations are the norm. For middle aged patients, I’m usually torn. Sometimes they’ll just tell me to use their first name. If the issue never comes up, I arbitrarily will switch between formal and informal, depending on my mood, my recollection of their personality, the lunar phase or potentially any other random irrelevant thought process.

Mrs. Silva (name changed) , who despite efforts to hide her age wearing bright ill fitting outfits and loud hats, was definitely 68 years old. No matter how hard she tried to look younger, I always used formal salutations.

“Mrs. Silva, what’s going on with the diabetes?”
“Well Dr. Hossain, I gotta be honest with you, I’ve been cheating more this past month.”

“Mrs. Silva, How’s Mr. Silva doing?”
“Oh he’s good. I keep telling him to make an appointment here. He won’t listen to me.”

“Mrs Silva, did you get your mammogram done?”
“Oh yeah! it’s not due until next month. I’ve already got it scheduled.”

“How’s the breathing Mrs. Silva?”
“It still stinks. I’m still always short of breath and no I haven’t stopped smoking yet Dr. Hossain. But I’m really gonna try these next few months.”

“Mrs. Silva, are you still coughing up a lot of junk?”
“Yeah Dr. Hossain. I can’t seem to shake this cough, even after the antibiotics. And I could’ve sworn I thought I saw a spot of blood in it.”

Soon after mentioning the last complaint, Mrs. Silva was diagnosed with Non small cell Lung cancer. Shortly after, it was discovered she had metastasis to the brain. Because of the myriad of oncology, surgery, neurology, neurosurgery, radiation oncology appointments, and 2 hospitalizations, she wasn’t able to make it for an appointment to my office. A few times she tried to schedule an appointment but cancelled. Throughout the process, we spoke on the phone a few times, and she remained delightfully optimistic and didn’t express any specific needs from me.

Finally, after 6 months, Mrs. Silva made it our office at the urging of her oncologist.. She had lost a great deal of weight and gave up the makeup and bright outfits for more demure, darker and simpler clothing. She lost all her hair but had a closet full of hats for this occasion. Since she was a resident clinic patient, the case was presented to me and I was well aware of all these details even before I walked in the room. I knew I would not be seeing the same Mrs. Silva.

I knocked on the exam room door and with a lump in my throat, ready to discuss some difficult issues.

“Hi. Dr. Hossain.”

I don’t recall what exactly went through my mind when I saw Mrs. Silva in front me, a shell of her former self. But I remember beginning the visit by trying to smile and saying,

“Hi Lily, how are you doing?”

3rd world medicines

       I routinely hear from relatives, how the medical system in my native country of Bangladesh is terrible. As a third world country, access to care, diagnostics and medications is a difficult everyday reality, especially for the millions in poverty. But even for those with money and access to the best care, my relatives often insist they don’t know what they’re doing. They complain to me and encourage their sick family members to find a way to get to a country with more advanced care. They tell me these things as I think about how physicians in 3rd world countries are excellent diagnosticians because they don’t rely as much on imaging or even blood tests. I think about how, despite our advanced technology and monetary investment in healthcare, our mortality data lags behind many other industrialized nations. I respect my elders and their belief in our healthcare system, and graciously accept their praise of my “expertise,” while secretly harboring skepticism towards their beliefs.
       Last year, I saw a 44 year old gentleman immigrant from Bangladesh who presented as a new patient. He had a fairly long list of medical problems for a young man. He had diabetes mellitus requiring insulin, he had a history of a coronary artery disease, high cholesterol, anxiety and depression. He was a pleasant gentlemen, who had been doing well without any particular chief complaint. His primary concern was getting refills on his medications. For the past 6 months, his physician in Bangladesh had been mailing them, but realized this was a dangerous proposition after 1 shipment was delayed and he missed a few doses. I looked at his medication list and didn’t recognize a single name except aspirin. After doing some research online, his deciphered medication list included an Angiotensin receptor blocker (ARB), a beta blocker, a statin, an ssri for depression, and a long acting insulin. It seemed like a very sensible evidence based regimen, and by all accounts had kept him symptom free, without any recent hospitalizations.
        Despite my preconceived notions about his health care in Bangladesh, I was thrilled at how well he was doing. As we were concluding the visit and I began renewing his medications, the dreaded “I” word reared its ugly head. He was a working man but unable to afford insurance yet. Quickly, I realized he would not be able to afford the ARB. I suggested an ACE inhibitor, which he recalled getting a cough from. But he would take it. We found the same beta blocker, except it wasn’t an extended release version, so he’d have to take it twice a day. He was on a brand name statin but now would have to settle for something less efficacious. The SSRI needed to be changed to something cheaper, despite its success. The insulin, despite being generically available here would be far more expensive than back home.
        In the spirit of full disclosure, I was embarrassed to tell my countryman, some of his new medications maybe inferior to what he was already on. He had a perplexed look on his face, waiting for an explanation. I have a hard enough time trying to cogently describe to a medical student or a resident, how our healthcare system operates, let alone an immigrant lay person. I couldn’t give him a straight answer, except to reassure him, we would make this current regimen work. His last question for me was whether he should finish the last 10 days of these 3rd world medicines. My 1st world expert training and sensibilities suggested yes.