Doctoring the Doctor-Patient Relationship

Medicine is a documentation heavy field, and advances in technology have brought computerized documentation to our doorstep. While there are advantages to patient care in using a computerized system, there are also several disadvantages, most of which I won't go into here. What I want to illustrate is the stark contrast between pre- and post- digitalization of patient care, and it's effect on the doctor-patient relationship.

Scenario 1:
Patient comes to urgent care clinic to see physician (MD). MD browses chart, enters room, introduces self, and has a 15 minute conversation with patient to try to arrive at a diagnosis. MD does a physical exam, then discusses the diagnosis or need for further work-up with the patient. MD retreats to office after patient visit to document the visit and finish paperwork. Total time for interaction: 30 minutes. Time focused on patient: close to 30 minutes.

Fine, you may not have 30 minutes per patient in the HMO setting. Humor me - am trying to make a point here. :)

Scenario 2:
Patient comes to urgent care clinic to see MD. MD enters room, introduces self, and settles in front of computer. MD pulls up template and quickly browses the computerized chart. Same 15 minutes used in conversation, however, as patient explains symptoms and answers questions, MD typing away, staring at computer screen to ensure accurate keyboard entries. Or, if MD a proficient typist, MD trying to maintain some semblance of eye contact while fingers madly typing away on keyboard. MD does a physican exam, then rushes back to the computer to enter physical exam findings. MD discusses the diagnosis or need for further work-up with the patient. MD then enters the appropriate referrals and other requests into the computer. Total time for interaction: 30 minutes. Time focused on patient: 5-10 minutes. Time with computer: too much.

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Common sense and documented research agree that patients consider bedside manner a very important skill; for some patients in certain situations, this may be possibly even more important that an extreme in medical expertise.

The advent of computerized charting brings concerns of a deterioration in bedside manner and further erosion of the patient-physician relationship. After all, once unacceptable things tend to become acceptable, even routine, after familiarization and practice. Even physicians who were once aware of the importance of good bedside manner may one day forget that staring at a screen while typing furiously is the antithesis of said manners. And what of the next generation, who will absorb computerized documentation as part of their training? Who will be there to remind them that it is not appropriate to sacrifice eye contact and associated nonverbal communication for the sake of technology, if their first introduction to clinical medicine involves residents and attendings modeling this behavior? How many more patients must we push away from the sterility of modern medicine before we realize something needs to change? Some physicians may look down upon "alternative" medicine, but what we can re-learn from them is excellent bedside manner - the ability to take a step back from all our technology and regain the skill to be present and use ourselves as part of the healing of our patients.

Are You the On-Call Doctor?

A Medley of Call Night Antics

7pm
nurse: are you on call tonight? Oh good, I've got the sister of Patient XXX on the phone and she wants to know what is going on with him.

Note to all relatives of people who are in the hospital: If you want to get in touch with the primary physician or the primary team taking care of your mother/father/brother/sister/cousin, please call in the morning. Early is better than late. Some physicians have afternoon clinics so they will not be available. Others, like surgeons, will be in the operating room and so will be harder to reach. If you call at 7pm chances are the physician you talk to will have very little detail on what the primary doctor is thinking and why they are doing what they are doing. Call in the morning. Early.

call from nurse at 2:30AM:

nurse: Hi, the patient has a foley catheter in place and is scheduled to have it taken out at 6am. Can I take it out now?

No. Unless there is imminent danger to the patient or others, it is never a good idea to change management plans at night when the primary doctor is not available. The doctor on call is covering all the patients in the hospital and does not know each patient well enough to make the best decision on management issues that are not critical at that point in time. This holds true for other noncritical management decisions, such as "should we change from an intravenous fluid with a little sugar in it to fluid without" or "do you really think we should do the orders Dr. X wrote earlier?" If Dr. X wrote it, and Dr. X is the primary physican caring for this patient who knows the patient well, and I am only the physician on call, and it is not a life or death issue, YES, you should follow the order that Dr. X wrote. I'm not going to second guess someone who knows the patient better, who may know certain details about the patient or his/her social situation, or past medical history that may affect why they order what they order. Medicine is an art and every physician has their own "style" of management. It's not my place to adjust another physician's style if it does not affect patient care.

call from the nurse at 3AM:

nurse: Hi, I have a patient here, Mr. X, who is wandering around. Could we get an order for Ativan?

Ativan is a sedative that can effectively knock someone out for the night. In elderly patients (majority of the hospitalized population), Ativan tends to be a suboptimal choice of sedative because of its side effects. Unfortunately, a number of them end of receiving this at night, even those that may not really have needed sedation in the first place - it's main purpose in certain situations is to ease the workload of the nurse. And unfortunately, physicians order it more often than needed, because if the nurse asks for it, and if the nurse isn't happy with your refusal to order it, they will call you. Again -- and again -- and again. Or worst, get mad, and the on call physician will be guaranteed many a sleepless night. From our point of view, it is extremely easy to just say yes, give Ativan if you would like to, but it's really not in the best interest of the patient or the primary team, who will find an extremely groggy patient who can't urinate in the next morning. It's much tougher to drag your butt out of bed to see the patient and assess the need for medical intervention, but it really is in the best interest of the patient. Most nurses are reasonable. If you see the patient, decide the medication is not indicated and discuss the situation with them, they are OK with not using a sedative. Some like getting their way. Like the nurse last night. Page #1: Patient had a little dementia and didn't want to stay in bed. I was in the middle of admitting a new patient and said that I would be up shortly to see the patient. Page #2: another nurse restating the same situation. Repeated my answer. Page #3: A third nurse stating that the patient was now agitated and threatening to leave. 3 in the morning, 3 pages, 3 nurses, 3 requests for ativan, all in 30 minutes. So I go to see the patient. He's standing in the hallway by himself, NOT agitated, NOT angry, NOT threatening to leave. The man is very pleasant, definitely advanced dementia with really poor short term memory. Based on the interaction, there was no acute need for sedating the patient. Tried to discuss this with the nurse, and had all three nurses in the wing crowding around describing how agitated the patient was and how he was climbing up and down and pulling things. Giving them the benefit of the doubt, as nurses are at the bedside and see more of the patient than we do, and given the fact that I was definitely not going to hear the end of it if they didn't get some sort of medication order, we compromised on a medication with less side effects that was to be used only if the patient was agitated. Riiiight... I'm sure it got used as soon as I left the floor. What can I say? There's only so much you can do... (Disclaimers: There are definitely situations where ativan is extremely useful, even in elderly patients. And not all nurses are like the nurses described in this situation - most of them are great.)

Worst phone call to have to make while on-call: calling the family of a patient you don't know who has passed away overnight.

2nd worst phone call: calling the coroner, who grills you with questions about the deceased patient that you just met. You sound like an idiot as you stammer and try to flip through the chart quickly to find the answers.

Time for bed.

Beluga Whales

How cute are these guys?

Beluga whales are small whales that live in artic waters. They are born grey but become white as they get older. Belugas are very social and playful animals, and have some characteristics that set them apart from other whales. They have a flexible neck and can "make faces" with their lips and forehead, so are often described as being very expressive. Apparently, at some aquariums around the world, the belugas go right up to the glass and make faces at the children, who return the favor. It's thought that the facial expressions assist in nonverbal communication in the wild (Ridgway and Harrison, 1981), but some wonder if the belugas antics are done for the children peering through the glass.

Belugas are called the "canaries of the sea" because of their varied vocalizations. Their calls have been described as barks, chirps, gurgles, grunts, groans, mews, moos, squeaks, trills, whistles, and yaps. Besides their natural sounds, beluga whales can also imitate the sounds made by people and other animals. A beluga whale named Logosi who lived at the Vancouver Aquarium in Canada even learned to say his own name.

Beluga whales create sounds by moving air between sacs near the blowhole. As the air moves from sac to sac, it is forced through the "lips" of the sacs. The air vibrates the lips as it passes, and these vibrations produce noise. Once vibrations have been produced, they pass through an organ called the melon. The melon, located inside the beluga's head, is a fatty ball that contains oils of different thicknesses. It is this organ that gives the beluga's forehead its rounded appearance. As it makes sounds, a beluga whale uses muscles in its head to change the shape of the melon. Doing this changes the oils a noise must pass through and changes the melon's thickness. A beluga controls its melon to fine-tune its vocalizations. (While singing, changes in the melon mean the forehead constantly changes shape.)

So cute.

I'm conflicted as to whether it's a good thing to have these wild creatures in captivity. Now, before you jump all over this, hear me out. It's not fair to the animals to have to undergo a traumatic capture and transport to an aquarium, where they live the rest of their lives confined in a relatively small and unchanging environment. It's wrong to hunt down an animal to add to aquarium income or increase their prestige. On the other hand, you have animals like Gasper, who were saved from even more dire environments. Of course, the ideal situation would be to treat his medical problems and once healthy, let him go back to the wild. But for those born in captivity, that may not be an option. What's done is done, and in these special circumstances, we should weigh the risks and benefits of captivity versus release and do what is in the best interest of the animal. If that happens to be captivity, then we should take advantage this special opportunity to learn from and treasure these magnificent creatures.

Tibetan Bell Ceremony

Was visiting a good friend in a fancy city. Said friend caught wind of an interesting event in town, so we headed over to a Tibetan ceremony the other night. Now, you may ask, what in the world is a Tibetan Bell Ceremony?

After the event, I still don't have a good answer for you.

It was performed by an American musician using not just Tibetan instruments and not just bells. I don't think Tibetans do this ceremony. It's one of those "foreign" things that if you asked a real "foreigner" they'd look at you as if you were crazy.

Anyways, the artist was a little strange, but most of the music he made was very enjoyable. He started off with some Native American flutes, the first one of which had an almost ethereal quality. Then he moved onto brass tibetan bowls, which when struck with a mallet produced very interesting tones. The "concert" also involved a ten foot long tibetan long horn, which produced a deep, almost earth trembling sound, tibetan bells, which were interesting, and my favorite, tibetan air cymbals, which created the crispest, freshest sound one can imagine.

The two favorites of the night were the native american flutes and the cymbals. I went straight to the library the next day to try to find some native american flute music, but alas, none of it had the same quality... I guess almost fifty years of sifting through instruments, as this particular musician had, means you end up with some priceless items... I wish you could have heard some of these sounds.

Breathe in, Breathe out

The last few posts have been ranting and raving about different subjects. It'd be hard to tell from these posts, but I really don't spend life running around mad. Really. Actually, I'm usually pretty happy go lucky... and I've had good things I've wanted to write about - great mentors, the joys of pets, etc - that are brewing around in the head and will one day make it on here. It's just that the rants poke through first... :D

What is in Our Food?

Have you ever thought about what unknown preservatives or additives are in your food? Or thought it strange when you read a can label and most of the ingredients seem like gibberish? One of the pitfalls from being so far remove from what we eat is that we have no idea what goes into it before we scarf it down. Contrast that to the farming communities of yore where you may break your back tending the food, but when you eat it, you know exactly what is in it.

Nowadays, meat comes in slabs, a far cry from what it actually looks like. Fruits come with a waxy, almost mirror-like sheen. Veggies come beautifully colored, with nary a insect in sight.

Little do we know it's been doctored... For example, did you know that beef, sashimi, and other red meat are often treated with carbon monoxide (yes, the gas that people die from) so that they retain a bright red color far past their freshness date. (Reminds me of the "cherry red" lips one is supposed to see in carbon monoxide poisoning.) Or that the reason your fruits and veggies are untouched by insects is that they know to stay away from the pesticides used? Check out the following:

Peaches and raspberries had the most pesticides detected on a single sample with nine pesticides on a single sample, followed by strawberries and apples, where eight pesticides were found on a single sample. Peaches had the most pesticides overall with some combination of up to 45 pesticides found on the samples tested, followed by raspberries with 39 pesticides and apples and strawberries, both with 36.

Spinach was the vegetable with the most pesticides detected on a single sample (10 found on one sample), followed by celery and sweet bell peppers (both with nine). Sweet bell peppers were the vegetable with the most pesticides overall with 39, followed by spinach at 36 and celery and potatoes, both with 29.

Here's the last thought I'll leave you with. Did you know that tofu contains either magnesium chloride, glucono-delta-lactone, or calcium sulfate (aka Plaster of Paris)? Or a combination of the above?

If you want more on this subject, check out these:

OK, enough posting for now. But seriously, isn't this disturbing?

The Fragility of You and Me

Friday's issue of the journal Science had an article on worms that thrive on undersea hot-water vents. Researchers brought the worms into the lab and tested the temperature range that they could withstand. The worms survived for as long as seven hours at 122 degrees Fahrenheit (50 degrees Celsius). Water of 140 degrees Fahrenheit (60 degrees Celsius) killed them. For comparison, a hot tub ranges from 100 to 105 degrees Fahrenheit. It was an interesting article but raised several points: 1) did we really need to drag the poor creatures from their homes and cook them alive/why is it OK for us to experiment on other animals 2) Although these worms like it warmer than you or I, we're not all that different. We both need very stringent parameters for survival.

If you think about it, there are certain things that we all need - oxygen, temperature, water, food, protection from radiation. For each of these variables, only a very small parameter is compatible with life.

- oxygen/altitude/pressure
The percentage of oxygen in the air at two miles (3.2 km.) is the same as at sea level (21%). However, the air pressure is 30% lower at the higher altitude because the atmosphere is less dense (the air molecules are farther apart). Most of us living near sea level develop hypoxia at 1-2 miles altitude. Climbers have reached peaks that are over 5 miles high, but only by using tanks of oxygen to assist in breathing.

- temperature
Normal body temperature is 37° C (98.6F). Below 94F. (34.4 C.) hypothermia starts to set in, and above 105F (40.6C) we run into problems where the brain and other internal organs start cooking. That's a whopping range of 10 degrees. Those of us fortunate to have air conditioning and heating may think this is less important, but even industrialized continents run into trouble - record heat wave in Europe (August 2003) claimed 35,000 lives.

- water
The human body is made up of ~60 -70% water and biochemical and metabolic processes that take place in the body depend on water. We just cannot survive without clean, drinkable water.

- food - calories, protein, fatty acids, minerals, vitamins
The lack of adequate nutrition leads to an endless list of medical problems, some maiming and some life-threatening: scurvy, beri-beri, pellagra, marasmus, anemia, goiter, night-blindness, birth defects, rickets/osteomalacia, blood clotting problems...

- protection from high levels of radiation
Stratospheric ozone is a naturally-occurring gas that filters the sun's ultraviolet (UV) radiation. UVB causes skin cancer, premature aging, cataracts, impaired response to immunizations, increased sensitivity to sunlight, and reactions to certain medications. Increased UV can also lead to reduced crop yield and disruptions in the marine life.

We have all these requirements for survival, but due to technology and luck that we live in the developed world, there's often a false sense of invincibility. We live blissfully unaware in our sheltered bubble. We celebrate the feats of extreme athletes, patting ourselves on the back for the brave representatives of the human race who push the borders of what is possible - i.e. those who climb everest - but we easily forget that extreme is relative. Imagine a snail congratulating another snail for making it up and down a big rock pile - after all, mountains are just transient elevations in topography - it doesn't change the fact that either snail will shrivel in the presence of salt.

Let's live and let live and take care of our planet. For those who think that environmentalism is just for the crunchy granola types, think again. We're all interconnected, and if you really pare it down to the basics, to irreversibly alter the world hurts fragile you and me.

Vaseline is a Wound's Friend

It's been a rainy, rainy spring.

I have this pair of flip flops that are old but oh so comfortable and I haven't found a suitable replacement pair. So I still wear them. Even though they no longer have tread and cause the wearer to slip at the slightest hint of water on the ground. Which just means that I have to remember when I can and cannot safely wear them.

Unfortunately a couple of weeks ago, I forgot to remember this point. In my defense, I went to walk the dog, and it was not raining at the time of departure. It did rain before we got home, but I actually slipped on a patch of overzealously watered lawn/walkway. And fortunately, don't ask how, I got away with a only couple of ugly scrapes on the foot.

The past weeks have been a lesson on wound healing. Suffice it to say that the conclusion is that I know very little about wound healing. I can tell you if a exploratory laparotomy scar looks well healed or "pussed out", or if someone has a skin infection, and have seen my fair share of nasty bed sores and leg ulcers, but have no idea what to do about the more routine scrapes. What I do know is that wounds heal faster and better when kept moist. Hence plastic surgeons and dermatologists, heck, even some emergency physicians, now slap on some bacitracin or other type of antibiotic ointment onto stitched up wounds.

--- Disclaimer: the faint of heart probably need not read any further. ---

So I set out on a mission to keep the wounds moist. Apparently, hydrogen peroxide for cleaning is NOT a good idea, because it damages the tissues more than it helps. Water, friends, water under pressure, is what it's all about when you're trying to clean out a wound. Too bad I found this out after using peroxide. Anyways, apparently, vaseline + band-aid is bad, as that led to maceration of the skin. But vaseline alone works. It seems to slow down and prevent a lot of the scab formation, which means it heals slower than expected. I mean, you're used to just seeing it dry out and scab over, after which it becomes itchy and gets scratched off. The delayed surface healing led to daily head scratchings as to whether or not what I was doing was correct. But now, more than a week out, I can safely say that keeping wounds moist is definitely the way to go. There's a small amount of scab formation, and most of the wound never scabbed over but is already pretty supple new skin with much less discoloration than expected. So the verdict is, vaseline is a wound's friend.

Probably more than you ever wanted to know about scrapes... :)

Disclaimer: This is not a medical advice blog. Wounds that are deep or infected, or otherwise dirty (ie dog or HUMAN bites) may need more treatment than the wound described above. Please see your primary care provider for any worrisome wounds.

Tragedy

Freak accident in Boston:

A scaffolding collapse killed three people on Monday. Twenty-eight-year-old Michael Tsan Ty of Roslindale was killed when the falling debris crushed his car. He was a neurology resident at Brigham and Women's Hospital. Also killed were construction workers Robert Beane of Templeton and Romildo Silva of Somerville.

I think I actually knew him peripherally in school... What sense can we make from this tragedy? Live life to the fullest every day because tomorrow is never a sure thing. Do what makes you happy - don't let it be a future goal. Work will go on, with us or without us. Enjoy all of life. As a wise professor once said, "the graveyards of the world are littered with the bodies of the indispensable."

On a side note, it's a shame that many of the media reports of this accident neglect to mention the two other unfortunate souls in the accident. Or if they are mentioned, they have half a sentence where Dr. Ty gets three or four. Dr. Ty definitely had a lot of accomplishments that we, as a society, think highly of, but I'm sure Mr. Beane and Mr. Silva lived equally important lives that were extremely meaningful to those who were affected them. R.I.P.

Word of the Day: Pandiculation

Keep track of the number of times you yawn while reading this:

Myth states that we yawn to get rid of extra carbon dioxide and take in more oxygen. In 1987, Provine* et al tested this idea on - who else - college students. They were given different gas mixtures to breath, one of which contained 100x the level of CO2 in normal air. Although respiratory rate increased, there were no differences in the number or duration of yawns between the normal air and the gas mixtures groups.

Every vertebrate species yawns but apparently it's only contagious in humans. As the good Dr. Seuss put it in his Sleep Book "A yawn is quite catching you see. Like a cough. It just takes one yawn to start other yawns off."

It's still unclear why yawns are contagious, but Provine has tested what triggers the yawning. When test subjects just see a yawning mouth, it doesn't trigger a yawn. But if the mouth is covered and the nose and eyes of the yawning face shows, it does.

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Have you yawned yet? :)

* Robert R. Provine is Professor of Psychology and Assistant Director of the Neuroscience Program at the University of Maryland Baltimore County.