Tuesday, February 28, 2012

Doctors choose less care compared to their patients

I've talked before about how I feel about end of life care. I want my patients to be comfortable. I want to avoid any interventions that are not going to improve quality of life. Patients and their families don't always agree with what I want. That's their prerogative. End of life is a scary time for people and involves decisions we hope to never have to make.

Patients who are doctors tend to choose end of life care with the least interventions.
"In a 2003 article, Joseph J. Gallo and others looked at what physicians want when it comes to end-of-life decisions. In a survey of 765 doctors, they found that 64% had created an advanced directive—specifying what steps should and should not be taken to save their lives should they become incapacitated. That compares to only about 20% for the general public."

It may be worth including these stats when discussing end of life care with our patients and their families. We are always told to use evidence based medicine, and to not ever answer "what would you do if you were me" with a straight answer. This seems like an ethically sound way to answer this question.

Monday, February 27, 2012

Kiddie food

I have a cute 11 month kiddo whose religion dictates that she not eat animal flesh. Milk and eggs are ok.

The kitchen in the hospital keeps sending her plain cod for almost every meal. No matter how many times the unit clerk has re-entered the order to be appropriate for the patient, we get plain cod.

Finally, I called dietary myself to get to the bottom of this. When I told them that my patient was strict vegetarian, I was told that was a vegan. He kept telling me that vegetarian meant fish. Strict vegetarian meant no milk.

I gave up and asked the kitchen to not bother with titles and just send yogurt and anything else they wanted as long as it never had a face.


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Sunday, February 26, 2012

Bear

When I travel, go on call, sleep on my couch or in my bed, I have bear.

I've had him since my second year of university. Without him, I have difficulty sleeping and end up using scrunched up towels as a poor substitute.

It's nice to know I'm not alone. 25% of British adults sleep with bears, though, most of that number are men. http://ca.news.yahoo.com/blogs/daily-buzz/survey-says-teddy-bears-accompany-many-british-adults-183611597.html

No matter how my day has been spinning out of control, Bear makes me feel grounded and helps me remember that sleep time is precious. Some days, feeling that my day is over is impossible until I am snuggled with Bear. There are no questions or expectations, no judgements or advice, just calm and softness.


Sigh.


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Saturday, February 25, 2012

Thank goodness Buffy didn't find out...

A teacher called CAS and they arranged to have a father arrested for possession of a firearm. He is a PSW, the people who do much of the dirty work in medicine. http://www.thestar.com/iphone/news/canada/article/1136659--kitchener-dad-arrested-at-school-after-daughter-draws-picture-of-gun

This started because his daughter had drawn a picture of her dad holding gun. He doesn't own a gun. Though even if he did, it would not necessarily be against the law in Canada.

I once drew a picture of my father as a vampire. I'm very glad Buffy the vampire slayer didn't see it.


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Thursday, February 16, 2012

The strippy quilt is coming together

I'm almost done sewing the quilt top together. Once I find a quilting needle for my machine I'll be able to finish putting it together.


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Monday, February 13, 2012

See one...

Usually in medicine, especially in the ED, you hear "see one, do one, teach one". This refers to seeing a procedure or technique done, doing it yourself then teaching someone else how.

In paediatrics however, it appears to be see one, see one, see one, see one, see one.....



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Sunday, February 12, 2012

Sunday morning at its finest

Chilling in bed with post secret, kitty, and my online news. If only I could magically make a coffee appear.


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Saturday, February 11, 2012

My friend is having a bad day. We live in different provinces so I can't give her a hug. Instead, I have these cute photos, mostly from cute overload.






























Hope you're feeling better sweetness!!!

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Location:Bad days

Friday, February 10, 2012

Medicine in Art

Take a look. Come to your own conclusions. Share if you like.
Frontier Surgery by Randy Steele

A tribute to a doctor by Sir Luke Fildes

Madness

Hope II by Gustav Klimt


Thursday, February 9, 2012

Residency Blues

Starting around 4-6 months into residency, almost universally, residents everywhere get hit with the blues. It is soul sucking and demoralizing to work every day, for what feels like millions of hours, at something that you are never really that good at.

We rotate through different specialities and disciplines every few weeks to every month or two. Our advisers change daily or weekly. Just when we think we're starting to get the hang of how this guy likes to see his notes written, or how she will think about making orders, we're thrown into a brand new situation.

Actual mastery of any domain is difficult to achieve because Family Medicine residents are meant to be exposed to as much as is possible so we get little time to hone our skills before moving on.

I'm in a community based program. This means that I'm in a small hospital which is great for being the only resident on and getting more chance for exposure to cases as they come through the door. It also means I'm the only resident who understands what I'm going through. Even though there are technically 4 of us in the hospital right now, we never see each other because we are never on service together. When we do see each other in the halls there is a flood of conversation, sympathetic smiles, and general advice from our experiences with the rotation before we need to move on.

I came from a large, very close class in med school. I miss them like crazy. We would frequently run into each other in the halls of the hospital while on clinical rotation and give each other pep talks before running on. We had small groups where we could all commiserate and hug and eat chocolate. We didn't feel alone. I knew that more than 140 other med students had my back, and they knew I had theirs.

I feel alone now.

Residency can be very isolating. I love my partner dearly, but he has no idea. He has always been my cheerleader and believes that I'm a rock star no matter how badly I mess up. Other residents get that we do make mistakes and they're horrible and say things like, "Well, you still have a good outcome...", or "No no no. THIS is a terrible mistake." We work through what went wrong and try to learn from it. Residents know how the teams in hospitals work and the questions to ask such as "wasn't there a note in the chart about the patient being diabetic?" This can really help to put things in perspective.

While I love that my partner thinks that no one is smarter than me and that everything will be perfect, it's difficult to believe after being raked over the coals by a preceptor for not knowing the full differential of rash in a 2 year old. It's not that I'm not willing to explain all the ins and outs of the interactions I have at work, but most days when I need to blow up, I just don't have the energy.

The problem with residents though is that they never really have time to chat. It takes forever to set up a good time for us to actually spend time together.

I'm looking for a good solution.

Wednesday, February 8, 2012

The most terrifying words I've ever heard

"Dr. Imposter we need you in the special care nursery STAT. RUN!"

I ran. And was terrified. I haven't learned paediatric resuscitation yet. Terrified.

Once I got there I was pretty much furniture. The RT and the nurses ran everything and made the baby go from yucky looking to feisty. These guys rock.

Once I could feel my feet again I asked the RT a million questions about what had happened, and I learned.

I also learned that I was not as calm in the face of a critically ill patient as I thought I'd be. That was eye opening.

I need more practice in dealing with scary situations. It's difficult to convince patients to let me make them critically ill so I can learn. (jokes)


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Everything I need to know about being a doctor I'm learning from Terry Pratchett: Cackling

I love the Disc World series by Terry Pratchett. It is just silly enough to be a great distraction after work and just serious enough to make me feel like an adult while reading it.

There are many witches in the series who act as the health providers in this world - there are doctors too, but those are usually men who are in the city rather than in the mountains where illness is actually happening.

In the stories of Tiffany Aching, an up and coming witch from a sheep farm, we get introduced to the culture of witching and what is expected of witches. These books are rich with, what I consider to be but could very well be far too self centred, analogies to being a physician in a rural setting.

A good example of this is "cackling" which is mentioned in several books and warned against, lest you turn into a Black Aliss and get stuffed in your own oven.

In "Wintersmith", page 17, Pratchett explains cackling:
'When you got right down to it, it was all about cackling. No one ever talked about this, though. Witches said things like "You can never be too old, too skinny, or too warty," but they never mentioned the cackling. Not properly. They watched out for it, though, all the time.

....

"Cackling," to a witch, didn't just mean nasty laughter. It meant your mind drifting away from its anchor. It meant you losing your grip. It meant loneliness and hard work and responsibility on other people's problems driving you crazy a little bit at a time, each bit so small that you'd hardly notice it until you thought that it was normal to stop washing and wear a kettle on your head. It meant you thinking that the fact you knew more than anyone else in your village made you better than them. It meant thinking that right and wrong were negotiable. And, in the end, it meant you "going to the dark," as the witches said. That was a bad road. At the end of that road were poisoned spinning wheels and gingerbread cottages. '

The witches of the Disc World visit each other to keep an eye on each other. Physicians work in similar circles and hear stories about one another though they are frequently not as forceful as Pratchett's witches who will tell a sister witch that they are beginning to cackle. Physicians tend to hope that their fellow docs will figure it out.

We have the CPSO for patients and doctors to report inappropriate or self destructive behaviour. I don't know, because I can't imagine how one would go about doing this research, but it seems that we are likely missing quite a few docs who have begun to cackle.

Looking at the back pages of the Dialogue magazine you see many examples of physicians who have let their minds "drift away from it's anchor". A compassionate person can look at the examples of narcotics mis-prescribing as easy to fall into. It can start with someone who is having a bad time and needs help with pain and with escaping their reality. You've done it once, why not do it again? Bit by bit this can escalate to trafficking - thugs on the street are doing it, why can't I?

Self prescription and self doctoring is extremely easy to fall into. I know enough to take care of these 2000 patients, of course I know enough to take care of myself! I can prescribe just what I need. But, we need someone else to keep us honest. Having a doctor as a physician is essential and I think works very well to keep our thoughts on track - if this doctor will treat us as a patient who is a doctor, not as a doctor who is a patient, by which I mean will take the time to explain a thought process and why they suggest a treatment rather than simply asking what medication the patient wants and dutifully writing a script. If you haven't seen the movie "The Doctor", it's worth checking out for this. There's a scene where the hero has hoarseness and his physician isn't worried because his patient isn't worried.

Taking care of patients without reflecting on what a wonderful privilege this is or how much they give back may leave some docs feeling empty and spent and looking for a way to fill their lives again. It may make them feel entitled to certain allowances such as not keeping proper records, charging extra fees not acceptable by their college or possibly, unfortunately, taking advantage of patients. There are far too many stories in the back pages of the Dialogue about sexual abuse of patients by doctors. To be honest, one story would be too many.

While I never expect to see a doc wearing a kettle on her head, I have seen docs who are a little bit lax on rules, guidelines, and expectations. I have yet to let these docs know that they are beginning to cackle. I hope this is because of my position as a lowly resident without any authority rather than not having the back bone to keep my colleagues from "going to the dark".

It would be awful to lose a friend to being shoved in an oven by a couple of kids.

Tuesday, February 7, 2012

My poor freaked out partner

We talk about stuff I've seen at work all the time. For the survival of my partner's tender sensibilities, I try to avoid topics that will upset him. These usually involve genitals and anything involving poop.

While he was listening to the Unbelievable Truth, a British comedy radio show, he learned some obstetrical facts that interested him.

The first was that newborn babies cry in the key of A.

The second had to do with episiotomy repairs. In particular, fourth degree tears and what outcomes one might expect. A very difficult topic to cover without discussing genitals or poop.


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Monday, February 6, 2012

Princess Peach

Kids love iPhones. They play games on them, watch YouTube, and take great photos.

Many of my patients play Super Mario. They have Wii machines in the hospital for them to use. I'll make these kids puppets from tongue depressors with Mario, Luigi, and Princess Peach. It's a cheap distraction that lets me examine bellies without voluntary guarding from the patient.

One of the patients had an iPhone with Super Mario on it. Watching him I was shocked at how quickly he was moving through the level. And ashamed of how poor I am at playing the game compared to a 4 year old.

Then his mom told me he was watching videos on YouTube of someone else playing the game.

D'oh.


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Sunday, February 5, 2012

Obese Physicians

The January web volume of the journal Obesity contained an article "Impact of Physician BMI on Obesity Care and Beliefs".


It found that physicians with normal BMI were more likely to engage their overweight and obese patients in conversations about weight loss than their obese colleagues. These docs also had greater confidence in their ability to counsel obese patients about exercise and diet. These docs also felt that the patients of doctors who are themselves obese would not trust those obese docs to give advice about their patients' obesity.


They also found that 93% of the docs would only diagnose a patient with obesity if they were confident that the patient weighed more than they did.


There are a couple of implications to these findings that I find concerning.


The first is that obese docs don't trust themselves to help their patients with obesity. It makes sense. Obese docs may feel ashamed that they are unable to control their own weight. I see it more like an AA sponsorship though. A doc who has dealt with weight issues may be better able to share their experiences and help patients avoid pitfalls. There may be less judgement. Though in AA, a sponsor has achieved sobriety. With obesity, it may be the doc who reaches a normal BMI who is best able to provide this support. One study showed that the patients of obese docs are more likely to have a normal BMI than the patients of doctors with normal BMIs. The Cardiac Exercise Research Group compared this to smoking doctors who are less likely to counsel their patients to stop smoking.


The second is that docs with normal BMIs have so little faith in their obese counterparts. Given the squeals of "ew" when images of MRIs of obese patients were shown in class during med school, I shouldn't be so surprised. I wonder what it would take to change these beliefs?


A third is that docs are most comfortable diagnosing obesity in patients who weigh more than them. The implication here is that even docs who have a normal BMI are judging their weights against that of their patients. That's sad.


What I find most disturbing about this article though is how other media have been presenting its findings. E.g. "Fat Doctors Can't Help Fat Patients"

While I wasn't able to find articles on patients' perceptions of fat doctors, the comments on some of the articles I looked at speak volumes. Essentially that they wouldn't give a fat doctor's advice on weight loss much weight, if you pardon the pun. I wonder if this would be different though if they actually met the doctors and developed a relationship with the doc.


When you learn about the ways to help a patient lose weight, we learn about motivation and goals. It may be my goal to be a doctor with a normal BMI, but my motivation is to be a doctor who will earn the trust of her patients. Further motivation for me to follow my New Year's resolution of following the advice I give to my patients.

Friday, February 3, 2012

Where's your ring?

With newborns we end up doing lots of calculations - total fluid intake needed, percentage weight loss, left shift of neutrophils, etc.

When working out weight loss out loud, a dad finished my thought with the answer "about 3.2%". Impressive.

I asked him where his ring was. He was very flattered because he assumed I wanted to know if he was available to be married since I was so impressed with his mad arithmetic skills. He was disappointed that I was looking for his engineers' iron ring.

For the record, I guessed correctly that he was an engineer, he just doesn't wear a ring.

Win!


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Thursday, February 2, 2012

Are you kidding me?

The ongoing joke right now on the post partum floor is that if a baby doesn't have a Sofi giraffe to go home with, children's aid society should be called immediately. These are the goofiest things I've seen. The claims that they are so good for teething, implication that they're better than other toys, is amusing to me. Kids love them. They're very cute. I'm sure they help with teething. Just don't know why everyone is compelled to buy them.



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