The Impostor

I just got my internal medicine evaluation. It's times like these that I feel like I've pulled the wool over everyone's eyes. My preceptor gave me "exceeds expectations" in almost all categories. I know that at more than one point I knew some thing she didn't know, but I really think that was just luck since I've been to so many conferences recently.

Preceptors always say "it may be just because of your background but...." it's their way of turning my older than average status into a positive. This one however was more specific - my experience and that I'm accustomed to working at all. I apparently have a strong work ethic.

When my patients tell me that they think I'm a great doctor, I assume it's just because they like my smile (or, like my little woman from Honduras, because they like my eyes). It's hard to believe that my patients know enough about the intricacies of what is going on behind the scenes to make these statements. That is so incredibly pompous of me to not think that my patients are able to make these assessments.

It's difficult for me to take compliments but maybe it's just as well because I always feel so stupid that I need to study constantly.


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6 months into residency

I didn't realise Christmas was already here. This means I didn't book off my PAIRO sanctioned 5 days. Also that I was not ready for Christmas. We improvised this year with a wire tree.

And yet, I feel relaxed and happy. I seriously am so very lucky to have such a brilliant job.


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Status quo

Convincing a group to stray from the highway of thought they've always been on can be ridiculously difficult. Ironic when at a meeting discussing leadership but not having people be brave enough to try something new.

At least the breakfast was yummy.




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No, sorry, I wasn't talking to you

We have been trained in medical school to talk to our patients when taking their histories - not to their family members or friends - whenever possible.

I ask 3 year olds where it hurts, 99 year olds with dementia what is bothering them. Even if your family member is a doctor or x-ray technician, I'd rather hear your story from you. Other people don't mean to, but they end up flavoring your story with their own interpretation of the situation. This can change how I think about your illness which does you no favours. It took me a while to develop any sort of strategy for dealing with friends and families who insist on talking for the patient. I tell them I appreciate their concern but that I really need to hear the information directly from the patient.

Ideally we have translators that are not related to the patient interpret languages we don't understand to avoid this kind of pre-interpretation. When interviewing patients through translation it can be difficult to watch the patient not the translator when the translator is speaking, and to speak directly to the patient. The first few times it feels awkward but eventually it does begin to come more easily.

Twice now I've had patient family members come up to talk to me but I haven't recognized them because I was more focused on my patient than them. I'm very proud of this fact.

Now switch to my friend Wanda who had been living in France. One Sunday morning she woke up feeling funky but not terrible. During brunch she became quite pale and dizzy. Her heart was racing and her husband kindly described her as looking like sh...

They went looking for a doc who took patients on Sunday. The closest was a few blocks away and on the third floor of an apartment building. He was located in the third circle from downtown, definitely should be respectable. His office smelt of cigar smoke, his breath of whiskey. Not surprisingly, Wanda was concerned and wanted to leave, but her husband knew she was sick and made her stay.

When this doc found out that Wanda did not speak French well, he ignored her completely and spoke only with her husband. "does she feel this?" etc. Absolutely awful. Then he grabbed a rocks glass off his shelf, looked in it, and handed it to Nick to have Wanda go pee in it.

After being handed the glass, the doctor stirred the chem strip in the glass, giving Wanda and Nick the impression he was using a swizzle stick and may take a sip at any moment.

Even though this doc made the correct diagnosis and cleared up Wanda's pyelonephritis, he gave the couple the impression that he was not a good physician.

By the way, the reason those family members wanted to talk to me was to tell me that my patient had really enjoyed the care they got and appreciated my advice. I'm hoping that this is something I can internalize and continue to do when my life as a doc gets busier and the temptation to talk to the 65year old daughter of the 85 year old tangential patient gets stronger and stronger.

(sorry if the details aren't perfect Wanda, I'm not used to telling true stories on here!)


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The ever expanding human spirit and jam jars

Something that almost all my non-medical friends ask me at one point or another is what embarrassing things patients have had to confess to me. In particular, things that patients have lodged in their behinds after "accidentally" falling on them.

I can't think of any of my own.

I have seen x-rays of others' cases though.

Most memorable was a jam jar. Not because it was particularly large, but because there is no tapering before a jam jar comes to it's full width.

As one butt curious friend put it, you should never underestimate the ever expanding power of the human spirit to get things done.


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Deep chart reviews

To save time and help guide our conversations when talking with patients, especially when doing consults, we will often look at old charts online and use previous consult notes.

The idea with doing this is that we will review our findings with our patients and/or their families to ensure that things are up to date. At 3 in the morning though, we sometimes get a bit lazy about making sure that everything we have written in the patient's past medical history is up to date and relevant.

We try to do the right thing by gathering information from multiple sources. We know what we need to be doing to be a good health care providers. I've been lazy and not checked info with patients, I know I'm not the only one. This makes me feel guilty and it should.

Mistakes get propagated when this happens. One patient I admitted had a mistake propagated through 3 years of consults. This patient had "bipolar disorder" in their past medical history, but did not have any psychiatric meds. I dug deeper in the chart and in the consult notes 4 years back I saw that the patient had been given a bipolar hip prosthetic. This is a fake hip with two sides to it, the cup and the ball. It is definitely not someone with an illness that should be treated with lithium or another mood stabilizer. Patients with psychiatric illnesses are treated differently than the general population. It's not something health care providers should be proud of. This was emphasized when my team realized the patient they had been explaining away cardiac symptoms as being caused by bipolar illness rather than following it up.

Another I've seen which has more dire consequences is pulmonary hypertension being changed to simple hypertension. The patient had low to normal blood pressure so the temptation to take him off his anti-hypertensives was strong. Doing this would have increased the pressure to the patient's lungs causing damage to the lung tissue.

Old notes can give us insight into a patient with chronic illness and how they first presented. Understanding our patients' health requires us to do more than skim past consult notes. We need to question those notes and make sure they are accurate. Since there are so many of us contributing to a patient's chart, we need to make sure that we use it as a communication tool. We are telling the next person who reviews the chart what the condition of our patient was at this point, and what we know their past medical history to be.

We also need to remember that these are legal documents and it's up to us to document only things we know to be true. If the history is impossible to obtain from the patient, which unfortunately often happens, we need to acknowledge that the history comes from old charts rather than from the patient.

At 3 in the morning when consults are pouring in it can be hard to remember to be diligent in out charting but our patients' health depends on it.


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Follow the bouncing ball

Hospitals have paths marked on their floors directing patients to the x-ray department, the exit, waiting rooms etc. These allow us to send the patients without escorts like nurses or porters. It saves the hospital money but allows the nurses to help other patients. It gives the patients some autonomy to get themselves from the ED to imaging. It also leads to them getting lost then feeling goofy for needing to ask for directions.



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