Do you still rely on your physical examination skills or put more faith in the test you order? Abraham Verghese present’s an awe-inspiring TED Talk on the power of the human hand in medicine and its use to touch, to comfort, to diagnose and to bring about treatment.

Has the patient in the bed become an icon for the patient in the computer?

http://www.youtube.com/watch?v=sxnlvwprf_c

Learn more about the teachings and brilliance of Joseph Bell in Smith, Bell and the Art of Observation.

Hat Tip: To Joe Lex over at Free Emergency Medicine Talks for also showing me this talk What the Pen Teaches the Stethoscope – By Abraham Verghese.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Life can be a battle…

However, thanks to the wonders of modern science, not only are we able to ‘medically‘ justify every ache, pain, whinge, grimace and gripe we suffer – but we are also offered a cure at the same time!

…and here is a new condition for you to ‘think you have’, a condition that will justify your ‘tiredness, angst and apathy’ – all at the same time!

Motivational Deficiency Disorder is proudly brought to you by Big Pharma companies you may remember from hype and marketing ploys ‘medical discoveries’ such as Female Sexual Dysfunction (FSD and FSAD), Oppositional Defiant Disorder (ODD), Restless Legs Syndrome (RLS – Free Cure, or Expensive cure), Oversized Male Genitalia (OMG) and Temper Dysregulation Disorder with Dysphoria (Normal KID)

But are you special enough to suffer form this new condition?

Well, if you have ever felt lazy, slovenly or just like ‘life is getting you down’, you may have Motivational Deficiency Disorder (MDD). One in five people suffer from this disorder and many don’t know they have it. This scientifically validated new test (p=0.3) will only take 30 seconds: it could save your life.*

1. Have you ever felt lazy or apathetic?                                                 Yes/No

2. Do you have a family history of laziness?                                          Yes/No

3. Do you ever feel tired on a Monday morning?                                  Yes/No

4. Have you ever considered hiring someone to clean the gutters?      Yes/No

5. Are you breathing?                                                                              Yes/No

*Argos L, et. al., Journal of Motivational Medicine, 2011 April 1;4:78-92

If you answered YES to just one question – you should see your doctor today!

http://www.youtube.com/watch?v=RoppJOtRLe4

…but why let the pharmaceutical industry have all the fun? Get onto the disease mongering generation engine and invent your own disease!

You never know, one of the newly developed drugs we have yet to find a role for….may just be the cure we haven’t been looking for!

Head on over to the Facebook Page to answer a question relating to RLS – our panel of experts are waiting for your responses!

More information on Disease Mongering

• PLoS Medicine Disease Mongering Collection
• Ray Moynihan: “Sex, Lies and Pharmaceuticals“ and “Selling Sickness“
• Overdiagnosis and the dangers of early detection [BMJ reference]
• Tiefer L, 2006 Female Sexual Dysfunction: A Case Study of Disease Mongering and Activist Resistance. PLoS Med 3(4): e178.doi:10.1371/journal.pmed.0030178 [Reference]

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

We all do it tough working in emergency departments, however watching the following videos from the ED and ICU in Bara hospital in Soweto, South Africa makes me feel like I have it easy.  The following videos tells of stories of patients being stabbed and arriving to hospital 10 hours later because that’s how long and ambulance takes to get to them. A single motor vehicle accident generally involves 12 patients, and a trauma patients generally receives their first few hours of care in the corridor.

24 hours of Trauma in the Emergency Department:

The Intensive Care Unit:

To watch more videos on Saving Soweto and the conditions doctors and nurses face working in the South African health system check out Aljazeera.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

OK, so it might just be my confirmation bias at play, but things really do seem to come in threes.

First I had to endure a discussion about the (in)efficacy of something called ‘homeopathic immunisation’. It wasn’t much of a discussion, I tried to stay calm, we agreed to disagree. I took a few deep breathes. However, it will at least make me fell better to air the following suggestion: don’t take your children on a holiday to the tropics if all they’ve had is ‘homeopathic immunisation’.

Next patient, next discussion. This one involved a detailed explanation about why I didn’t want to prescribe antibiotics (in addition to the naturopathic medications the child was already being assaulted with) for a viral illness. Again, I tried to maintain equanamity. After all, the family will no doubt be off to the GP during business hours to get the script that they came for. I started to wonder about the availability of places on an upcoming anger management course.

My next patient was a child with gastroenteritis. His father said that he wasn’t taking any medications. Except… wait for it… “some homeopathic remedies”. The father shrugged his shoulders, “his grandmother’s a homeopath”.

I paused as I turned from the child to look at the father.

“You know, this is a situation where homeopathic remedies probably help.”

The father looked surprised.

“After all, if its got water in it, its gotta be good for gastro.”

The father seemed to choke. I looked around for a large bore cannula. However, I soon realised this was just the prodromal phase of an extremely violent episode of laughter.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

We’ve talked about situational awareness and sense-making on LITFL before. We need to recognise that something needs to be done for it to happen, even if we actually know what to do. Teamwork and the influence of human factors are critical to achieving this.

This is emphasised by Martin Bromiley’s harrowing personal experience, and his incredibly constructive response to help improve healthcare:

“As a result of his personal experience, Martin Bromiley founded the Clinical Human Factors Group in 2007. This group brings together experts, clinicians and enthusiasts who have an interest in placing the understanding of human factors at the heart of improving patient safety.”

“In Just A Routine Operation Martin talks about his experience of losing his wife during an apparently routine procedure and his hopes for making a change to practice in healthcare.”

Just A Routine Operation from thinkpublic on Vimeo.

Visit the NHS webpage on Human Factors.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

A few years ago I was looking after an elderly woman in the emergency department who had suffered a stroke. She was aphasic — unable to understand speech or create comprehensible sentences. I explained to her family what had happened to her. Then her daughter asked me a question for which I hadn’t prepared an answer:

“What does it feel like to have a stroke?”

The answer to this question is not taught in medical school. I could call on a few vague recollections from some of Oliver Sacks‘ books, but the place I directed her to was TED.com and a talk by the neuroscientist Jill Bolte Taylor. Taylor wrote a book titled My Stroke of Insight based on her own experience of a hemorrhagic stroke. The fusion of her objective scientific approach with her personal, subjective internal adventure gives an incredible unique insight into the effect of an intracerebral hemorrhage on the human mind.

Watch, learn and be amazed:

http://www.youtube.com/watch?v=UyyjU8fzEYU

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Treat the patient, not the disease

Care more particularly for the individual patient than for the especial features of the disease.
— William Osler

We enter medical school eager to help the sick and the dying. Over the years this golden objective is transmuted into the base lead of disease-specific diagnostics and therapeutics. Our absorption in the strangeness of the manifestations of a remarkable pathophysiological process may distract us from its impact on the person.

Olser warned us of this danger:

There is a tendency among young men about hospitals to study the cases, not the patients, and in the interest they take in the disease lose sight of the individual. Strive against this.
— William Osler

This tendency is dangerous. Failure to temper it comes with undeniable costs. The elderly may die alone in sterile surroundings rather than a home filled with the memories of loved ones. The symptoms of disease may be replaced with the side-effects of therapy. Autonomy may be sacrificed for dependence at the altar of medical paternalism.

This tendency turns us into misguided Ptolemaic medico-astronomers when we forget that the patient is the center of the medical universe. Perhaps we can be forgiven. After all, we find ourselves buried under mountains and mountains of facts and figures and guidelines and ‘the latest’ in evidence. We are stamped and punched with holes by the grinding and boring down of the ‘health care’ machine. We are worn away by the diminishing returns of circadian disruption won by playing a loaded game of roster roulette. And, perhaps the pill that is hardest to swallow, we sometimes find ourselves the target of vehement violence and abuse by those we try to help. Perhaps we can be forgiven for forgetting just what it is that is the Philosopher’s Stone of our profession.

All the more reason to remember the lessons of Osler.

"Observation, Auscultation, Palpation, and Contemplation" from Library and Archives Canada (Click image for source).

In his or her first days of becoming a doctor, the once and former medical student comes to a deflating realisation. The patients have not read the textbooks or attended the lectures. The child with abdominal pain has pneumonia, the slightly crazy man with all over body ache didn’t even mention chest pain as a symptom of his myocarditis, and the man with the shrinking feet isn’t crazy (even though his feet are not shrinking). Osler reminds us that this state of affairs is nothing new:

Our study is man, as the subject of accidents or disease. Were he always, inside and outside, cast in the same mould, instead of differing from his fellow man as much in constitution and in his reaction to stimulus as in feature, we should ere this have reached some settled principles in our art.
— William Osler, from Teacher and Student, in Aequanimitas.

As doctors our learning is a lifelong task. Everyday we learn new lessons. And who teaches us? Our patients. Everyday I hear the words of one of my own teachers, Prof Koelmeyer, who would admonish us to remember that the patient is “our first, last, and only teacher”.

But what of the difficult patient?

Indeed, difficult patients present great difficulties. They sap our physical and emotional reserves, they disrupt the under-oiled workings of the hospital conveyor belt, they confront us, and may even be a physical threat to us or put the ‘Mark of the Beast‘ upon us. The threat of physical violence towards hospital staff is never to be tolerated, no matter who the patient is. However, sometimes this threat comes from those who know not what they are doing. We must guard against making assumptions and try to help. Aequanimitas cannot always be maintained and, sometimes, ‘Freudian slaps‘ will be proffered.

Yet each difficult patient teaches us a lesson. With each lesson we become better at treating difficult patients. With time some patients that we once considered difficult, no longer merit the disdained classification. They simply become patients.

Every patient you see is a lesson in much more than the malady from which he suffers.
— William Osler, from The Student Life, in Aequanimitas, 406.

But treating the difficult patient is made easier by more than just the fact that they are our teachers. They allow us to prove our humanity and remind us why we do what we do.

To serve the art of medicine as it should be served, one must love his fellow man.
— William Osler

Despite all of medicine’s scientific advances and technological marvels, empathy is still at the heart of our profession. Empathy is a two-way street, there are times when, one way or another, we suffer together with our patients. But what to do when we open the empathy cupboard and find it bare? Sometimes empathy is simply an impossibility, we just have to be professional. But much of the time we just need to think of ourselves — or that still much-loved black sheep among our friends and family — and remember that we also are all too human with our own unique complex of flaws and frailties.

Keep a looking glass in your own heart, and the more carefully you scan your own frailties, the more tender you are for those of your fellow creatures.
— William Osler

Though it may be difficult in this era of ‘four hour rules‘ and the tyranny of QPIs, today as in the past, doctors do well to heed Osler’s wise counsel:

The motto of each of you as you undertake the examination and treatment of a case should be “put yourself in his place: realize, so far as you can, the mental state of the patient, enter into his feelings… Scan gently his faults. The kindly word, the cheerful greeting, the sympathetic look.
— Wiliam Osler

Though it is not always easy, or even possible, there is much to be gained by always striving to treat the patient, not the disease.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The associations that populate our minds are wonderful things. To some degree they make us who we are. To what thoughts does your mind race as you contemplate this banana, I wonder?

Photo by Jason Gulledge

Perhaps some of your evoked associations may not be fit for public dissemination. Fair enough, your privacy should be respected.

Among my own associations I can bring forth the image of a little old lady. I can see her calmly sitting in her hospital bed in the rehab ward. She was afflicted with a lesion to one of her frontal lobes. Her potassium was running a bit low. One of my colleagues was speaking to her.

“Here have an extra banana, it will help boost your potassium levels”, he happily suggested.

The patient appeared nonplussed, her eyes fixed on the banana.

After a brief pause she reached out and took it in her spidery grasp.

Then she spoke to my smiling colleague.

“I’ll tell you what to do with this banana…”, her voice filled with unexpected vitriol, “take it over there, and stick it up your mate’s…”

Startled that the banana was now being directed at me, I failed to register the finer details of the intended location.

Fortunately, I never did find out.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Croakey recently published part 3 of their series on health reform in Australia. It features comments from Clare Skinner, an emergency medicine registrar in Sydney, on the introduction of the ‘4 hour rule‘ to Australia’s emergency departments.

Dr Skinner highlights that,

“implementation will require major cultural and workplace change, including improved co-operation between clinicians working in the Emergency Department and inpatient specialist teams.”

She goes on to highlight a problem that will ring true with emergency doctors Australia-wide – as well as many of our colleagues overseas:

“During a recent shift, I watched a senior Emergency Physician spend almost four hours on the telephone, negotiating admission of a single patient with a relatively simple primary problem, but complex medical history, to a specialist inpatient unit.”

Perhaps an even worse predicament – and one of my pet peeves – is that of the public hospital emergency doctor looking after a privately insured patient who needs admission. I am not alone in having spent countless hours on the telephone speaking to private hospital ‘bed state’ managers and on call private physicians while trying to find placement for a patient with private insurance. Given that it is presumably in their business interests to have patients, surely they should be ringing us and not vice versa? Maybe I just don’t understand private medicine. In fact, I’m sure I don’t – is it an oxymoron?

“Since…gomers [Get Out of My Emergency Room] don’t die…the tern [intern] had to find other ways to turf them…The problem with the turf was that the patient might bounce, i.e. get turfed back…The secret of the professional turf that did not bounce, said the Fatman [a supervising Resident], was the buff…‘Because you gotta always remember: you’re not the only one trying to turf. Every tern and resident in the House of God is lying awake at night thinking how to buff and turf these gomers somewhere else.”

“‘[That doctor’s] so scared of missing something by sending the patient back home that he admits them all. He’s a sieve…he lets everyone through…Be a wall. Don’t let anyone in.’…A mind-boggling thought: the delivery of medical care consisted of buffing and turfing the seeker of care to somewhere else. The revolving door with that eternally revolving door always waiting in the end.”
- from ‘The House of God‘ by Samuel Shem, quoted in Nugas P, et al (2009)

Dr Skinner also mentions a solution offered by a recent must-read qualitative study by Nugas P, et al (2009) – namely the teaching of ‘Selling, Marketing and Packaging 101 to Emergency Physicians and GPs’. Dr Skinner, however, offers another solution:

“Open more beds, aiming for 85% occupancy, to put an end to chronic bed block.  Re-invigorate generalism, through funding and employment strategies which reward holistic medical care, rather than super-specialised procedural work.  Appreciate and support Emergency Physicians and trainees, with their unique skill-set and system-based approach, as they aim to provide the best care to their patients.”

While we wait (and hope) for this particular pig to start flying, we simply have to accept that the selling and marketing of patients is a sad reality of current emergency medicine practice. Indeed it is impossible to be a productive emergency medicine doctor without developing powers of telephone persuasion.

Intern to researcher: “I’ll ring the med reg [medicalregistrar]“. Phoned: “Hi, it’s ‘Trudy’ herefrom emergency. I have a patient that needs admitting…He’sgot a history of acute appendicitis [Consultant behind — looksexasperated]…OK. Bye.”
[Consultant]: “What did he say?” Intern:”He said call the surg reg.”
[Consultant]: “Of course he did.You don’t tell him he’s got a history of appendicitis.That’s an easy bounce straight to surgery.”
- an interview excerpt from Nugas P, et al (2009)

I’ve poked fun at this marketing side of emergency medicine practice before, using the superb satirical work of Grant Innes on the disposition of the ‘Patient Without Discernible Pathology‘ (PWDP). However, I’ve also emphasized the serious need for teaching junior doctors the communication expertise necessary for referring patients from the emergency department, as championed by the work of Chad Kessler. Using these skills, if the objective of ‘do what is best for the patient’ and the ‘platinum rule’ of ‘treating others as they would like to be treated’ are remembered, it is possible to ‘market’ patients to admitting teams ethically and effectively.

But can it remain so under the 4 hour rule?

References

• Innes G (2000). Successful hospitalization of patients with no discernible pathology. CJEM, 2 (1), 47-51 PMID: 17637127
• Nugus P, Bridges J, & Braithwaite J (2009). Selling patients. BMJ, 339: b5201 PMID: 20008442

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

UCEM‘s PR Supervisor, Assistant Sub-Professor Egerton Yorick Davis IV, has kindly released the new UCEM guideline, ‘Putting Patients at Ease’, to the LitFL team. This marvel of pedagogical pedantry was assembled by a crack team of educators under the direction of the incomparable Professor Harry Stickler. It serves as a guide for MUPPETs to a key Waiting Room medicine competency: the art of instantly and effortlessly putting patients at ease. The guideline adheres to the Sticklerian philosophy that the best way to learn how to do something is to first learn how NOT to do it.

So, without further ado, here are some UCEM-sanctioned pearls for how NOT to put your patient at ease, how NOT to build rapport and how NOT to make the patient think you’re the right doc for the job.

http://www.youtube.com/watch?v=m1IGH-WKW38

While introducing yourself to the patient, say:

• “Oh, you’re not Mr Smith? Whose clinical records are these then?”
• “Are you sure you’re not Mr Smith? Are you in the right cubicle?”
• “Mr Smith, sorry about the delay… I’ve just been examining the wrong patient.”
• “Sorry, my mistake Mrs. Smith, I understand now. You’re not his grand-mother, you’re his wife.”

While examining a patient:

• swing you stethoscope around your neck, such that you hit yourself in the eye and a juicy periorbital hematoma starts to form.
• scream “What the hell is that?!?”
• mention to the patient’s father, “he really doesn’t look anything like you, does he?”
• squeeze the abdomen so hard that the patient lets out an involuntary fart.
• gently pat your non-pregnant patient on the belly and say, “well, you’re sure getting big… Tell me again, when are you due?”

Before a procedure:

• vomit or drip sweat onto the patient.
• start reading a textbook in front of the patient. After 2 minutes turn the book the right way up.
• inquire of the patient, “Are you sure it’s this leg, I mean arm?”
• say to the patient, “I’m feeling a bit shaky, can I have one of your beta-blockers?”
• reassure the patient that “if this doesn’t work out we can always refer you to Plastics.”
• explain to the patient with abdominal pain, “Look we’ve got no idea what’s going on, so we’re going to cut you open. OK?”
• confidently assert, “Don’t worry about a thing, I’m much smarter than I look.”

During a procedure, say:

• to the nurse: “Hmm, have I given the local anesthetic yet?”
• “I wish I’d seen this done before”.
• “Damn it, I should have used my dominant hand for that bit”.
• “You know, maybe we should just start this all over again.”
• “I think its stuck”  (this is especially effective during a speculum exam).
• “Oh, no…”
• “It’s OK, I’ll just hold this here until help arrives.”

After a procedure, say:

• “Wow, that was great – my first one!”
• “Wasn’t there another swab around here somewhere?”
• “Well, at least it went better than the last one I did.”
• “Mr. Smith, it appears that my hand has been glued to your head.”
• “Just remind me, what did I say was wrong with you?”

http://www.youtube.com/watch?v=EYPsCWli-go

Life in the Fast Lane Medical Blog - Emergency Medicine education blog