You've been late because you pulled over to help a farmer get his sly sheep off the road. They are damn cute though.
- Posted using BlogPress from my iPhone
Tuesday, July 30, 2013
Monday, July 29, 2013
Oh the pity I felt for this patient
Allergic to bacon!! AND chocolate!! I'm not sure I'd be able to go on living.
- Posted using BlogPress from my iPhone
- Posted using BlogPress from my iPhone
Saturday, July 27, 2013
Can I possibly improve my blog? Maybe.
For kicks, I decided to look on PubMed to see if there was any research done on blogging. There is. Actual research done on how docs blog. Cool. But it's Saturday, so I'm only going to look at 2 of them.
First of all, did you know about Web 2.0?? I sure didn't but I've been using it like a mad person for years. Web 2.0 describes web sites that use technology beyond the static pages of earlier web sites.
This article makes a point I've been considering for a while - making my blog searchable in a way that will make it easier to match experiences I've had with my progress in my training and any applicable social aspects. They propose that bloggers use the usual tags they use (my favourite seems to be 'note to self''), they call these folksonomy - plus a diagnostic code from the ICD-11. The blogs that the researchers suggest these tags be used include WebMD, Kevin MD, and CasesBlog. My blog has little to do with these blogs - it's just me, I'm trying to learn more about myself as a physician not necessarily educate others (though I hope that's a happy bonus), and, for the most part, I hide my patients' true diagnosis. If I choose to follow the proposed system in this paper, which frankly isn't terrible, it makes it more difficult to hide my patients' identity. Unless, I use the ICD codes only for my rants on specific topics like suicide and HIV, and ignore the diagnoses of the cases I dissect. Which certainly is something worth looking at. While I won't follow their algorithm to the letter, I will try to remember to tag liberally.
Another set of researchers looked specifically at learners' blogs. It's like they were looking over my shoulder. They found that learners used their blogs to reflect on their experiences. Their table 2 looks at the analysis of the blogs and what is covered and offers a few suggestions. My absolute favourite is the suggestion to share coping strategies with peers. Personally, I would have put it under "emotional distress" not "interaction with peers". I think that many learners are looking for other learners' blogs to find out how they deal with the big stuff in their lives - exams, residency matching, patient death... Having a fairly anonymous way of talking about things we are afraid of telling each other face to face would be helpful. There are many conversations taking place on twitter and in medical journals about burnout. It seems to me that using each other via the anonymity of Web 2.0 is one way to seek help without worrying about repercussions.
They also found that blogging learners were likely to preach the benefits both of collaborative learning and having a solid support system. Of course they do. Blogging learners rock.
Pinilla et al also makes some suggestions about how medical educators can use their students' blogs to enhance their learning. One suggestions is that the educators look for where their learners are having problems with exams, etc. This creeps me out. If I had any inkling that my teachers were looking at my blog I would have stopped writing. Or at least edited my posts to the point of ruining the point I was trying to make. Random, unknown educators would have been welcome to peruse, but not my own teachers. Looking at broad themes and concerns of the bloggers in general is a great idea. That it might even be an option makes me happy that I've stayed the Imposter.
So, to recap what I've learned:
1. Tag my blog liberally so that finding information in the future will be easy, both for me and for my readers.
2. Encourage the use of blogs as a way to share coping strategies.
3. Blogging learners rock.
4. Educators should not follow their own learners' blogs. It's creepy. But I'm all for qualitative research. Especially when it's done by someone else.
First of all, did you know about Web 2.0?? I sure didn't but I've been using it like a mad person for years. Web 2.0 describes web sites that use technology beyond the static pages of earlier web sites.
This article makes a point I've been considering for a while - making my blog searchable in a way that will make it easier to match experiences I've had with my progress in my training and any applicable social aspects. They propose that bloggers use the usual tags they use (my favourite seems to be 'note to self''), they call these folksonomy - plus a diagnostic code from the ICD-11. The blogs that the researchers suggest these tags be used include WebMD, Kevin MD, and CasesBlog. My blog has little to do with these blogs - it's just me, I'm trying to learn more about myself as a physician not necessarily educate others (though I hope that's a happy bonus), and, for the most part, I hide my patients' true diagnosis. If I choose to follow the proposed system in this paper, which frankly isn't terrible, it makes it more difficult to hide my patients' identity. Unless, I use the ICD codes only for my rants on specific topics like suicide and HIV, and ignore the diagnoses of the cases I dissect. Which certainly is something worth looking at. While I won't follow their algorithm to the letter, I will try to remember to tag liberally.
Another set of researchers looked specifically at learners' blogs. It's like they were looking over my shoulder. They found that learners used their blogs to reflect on their experiences. Their table 2 looks at the analysis of the blogs and what is covered and offers a few suggestions. My absolute favourite is the suggestion to share coping strategies with peers. Personally, I would have put it under "emotional distress" not "interaction with peers". I think that many learners are looking for other learners' blogs to find out how they deal with the big stuff in their lives - exams, residency matching, patient death... Having a fairly anonymous way of talking about things we are afraid of telling each other face to face would be helpful. There are many conversations taking place on twitter and in medical journals about burnout. It seems to me that using each other via the anonymity of Web 2.0 is one way to seek help without worrying about repercussions.
They also found that blogging learners were likely to preach the benefits both of collaborative learning and having a solid support system. Of course they do. Blogging learners rock.
Pinilla et al also makes some suggestions about how medical educators can use their students' blogs to enhance their learning. One suggestions is that the educators look for where their learners are having problems with exams, etc. This creeps me out. If I had any inkling that my teachers were looking at my blog I would have stopped writing. Or at least edited my posts to the point of ruining the point I was trying to make. Random, unknown educators would have been welcome to peruse, but not my own teachers. Looking at broad themes and concerns of the bloggers in general is a great idea. That it might even be an option makes me happy that I've stayed the Imposter.
So, to recap what I've learned:
1. Tag my blog liberally so that finding information in the future will be easy, both for me and for my readers.
2. Encourage the use of blogs as a way to share coping strategies.
3. Blogging learners rock.
4. Educators should not follow their own learners' blogs. It's creepy. But I'm all for qualitative research. Especially when it's done by someone else.
Thursday, July 25, 2013
A True Love Story
First things first. Go get some tissue. Sincerely.
Next, watch this video. It's beautiful. Seriously. Watch it.
Did you love it? Of course you did. Daily love letters? Planning for a partner's life after you die?
Now you may continue.
This is a love story that I first learned about more than 10 years ago. They were one of my favourite couples who came to my restaurant when I was serving. They came from India during a time when you did not date outside your caste. Especially not the untouchables, but love goes beyond these invisible borders when you are good people.
They went to school and were educated in medical fields. One became a brilliant researcher and teacher, the other a fantastic clinician working to save lives. I have had the honour of hearing stories from the students and patients of these couples. They are well loved by those they serve.
The love they feel for each other was obvious in their dealings with each other - the tenderness they showed one another over their table through touch and words, the way they shared their meals, Mrs. would always bring home a treat for Mr. when he wasn't able to make it to dinner. They would tell me stories of their courting and their move from India to Canada. I would often end in happy tears with the two of them. (by the way, can you see why Family Medicine had to be where I'd end up?)
Fast forward over my medical training.
I am doing a hospital elective in the town I used to live in, where I first met the brilliant couple.
We are paged to see a patient who is not doing well. There is a long history of cancer and chemo complications. I'm shocked to recognise my Mr. Love Story on the hospital bed. He looks unwell. Very unwell. I can tell immediately that he's actively dying.
We catch up, I learn the course of his metastatic prostate cancer over the past year. About all the treatments he has been through for the past year. About how Mrs. LS has never left his side, sleeping many nights by his hospital beds. The entire time, they are holding hands, looking at each other with the doe eyes I didn't even know I had missed. Mrs. LS tells me that the love she feels for Mr. LS is only growing stronger through all of this. Mr. LS's biggest concern is that he is leaving Mrs. LS with unfinished business. And how will she continue without him around? Their children will be some comfort but, as with all families, they are busy.
Next comes the part I hate the most. The goals of care talk.
They think they are in the ED for a quick fix so they can go home together. I tell them I think that Mr. LS is dying. They aren't surprised but they are sad. Mr. and Mrs. LS want to have a few more months together. I'm hoping for a week. Mostly I'm annoyed that the colleagues of the LS's didn't let them know (or at least ensure they understood) during their treatments that Mr. LS was dying. I know it's hard to have perspective when the patient is someone you know. I learned that it is even harder when it's someone you love.
My colleague came to see the LSs and did the evaluation. My visit was to determine goals of care and ease the conversation for the next doc to evaluate and admit Mr. LS. The next doc came and told me that my week was overly optimistic and that Mr. LS would not have more than a day.
The funeral service was beautiful. Both communities came out to celebrate the life of Mr. LS and the love between him and Mrs. LS.
As with most of these painful encounters. I want to learn.
Lessons learned here:
1. Love stories are important. They are everywhere and give us something to hold onto when everything else is crappy. Ask patients and find out what their love story looks like.
2. Having perspective with patients who you are emotionally attached to is impossible. Ask for help. Know where the boundaries are.
3. Find out patient expectations early in the interaction to best help your patient.
4. Serving others provides your emotional self with great nourishment and can allow a love to grow exponentially through adversity. I served food as a waitress but now I serve my patients. I am constantly overwhelmed by the lives my patients live and their willingness to share these lives with me.
Next, watch this video. It's beautiful. Seriously. Watch it.
Did you love it? Of course you did. Daily love letters? Planning for a partner's life after you die?
Now you may continue.
This is a love story that I first learned about more than 10 years ago. They were one of my favourite couples who came to my restaurant when I was serving. They came from India during a time when you did not date outside your caste. Especially not the untouchables, but love goes beyond these invisible borders when you are good people.
They went to school and were educated in medical fields. One became a brilliant researcher and teacher, the other a fantastic clinician working to save lives. I have had the honour of hearing stories from the students and patients of these couples. They are well loved by those they serve.
The love they feel for each other was obvious in their dealings with each other - the tenderness they showed one another over their table through touch and words, the way they shared their meals, Mrs. would always bring home a treat for Mr. when he wasn't able to make it to dinner. They would tell me stories of their courting and their move from India to Canada. I would often end in happy tears with the two of them. (by the way, can you see why Family Medicine had to be where I'd end up?)
Fast forward over my medical training.
I am doing a hospital elective in the town I used to live in, where I first met the brilliant couple.
We are paged to see a patient who is not doing well. There is a long history of cancer and chemo complications. I'm shocked to recognise my Mr. Love Story on the hospital bed. He looks unwell. Very unwell. I can tell immediately that he's actively dying.
We catch up, I learn the course of his metastatic prostate cancer over the past year. About all the treatments he has been through for the past year. About how Mrs. LS has never left his side, sleeping many nights by his hospital beds. The entire time, they are holding hands, looking at each other with the doe eyes I didn't even know I had missed. Mrs. LS tells me that the love she feels for Mr. LS is only growing stronger through all of this. Mr. LS's biggest concern is that he is leaving Mrs. LS with unfinished business. And how will she continue without him around? Their children will be some comfort but, as with all families, they are busy.
Next comes the part I hate the most. The goals of care talk.
They think they are in the ED for a quick fix so they can go home together. I tell them I think that Mr. LS is dying. They aren't surprised but they are sad. Mr. and Mrs. LS want to have a few more months together. I'm hoping for a week. Mostly I'm annoyed that the colleagues of the LS's didn't let them know (or at least ensure they understood) during their treatments that Mr. LS was dying. I know it's hard to have perspective when the patient is someone you know. I learned that it is even harder when it's someone you love.
My colleague came to see the LSs and did the evaluation. My visit was to determine goals of care and ease the conversation for the next doc to evaluate and admit Mr. LS. The next doc came and told me that my week was overly optimistic and that Mr. LS would not have more than a day.
The funeral service was beautiful. Both communities came out to celebrate the life of Mr. LS and the love between him and Mrs. LS.
As with most of these painful encounters. I want to learn.
Lessons learned here:
1. Love stories are important. They are everywhere and give us something to hold onto when everything else is crappy. Ask patients and find out what their love story looks like.
2. Having perspective with patients who you are emotionally attached to is impossible. Ask for help. Know where the boundaries are.
3. Find out patient expectations early in the interaction to best help your patient.
4. Serving others provides your emotional self with great nourishment and can allow a love to grow exponentially through adversity. I served food as a waitress but now I serve my patients. I am constantly overwhelmed by the lives my patients live and their willingness to share these lives with me.
Monday, July 22, 2013
Pill Rolling Tremor
I'm on vacation while I wait for the FHT to sort out the red tape in me joining the practice. This is giving me time to sort through questions that have come up during residency.
One was after a disagreement I had with a doc about what a pill rolling tremor is. The doc I was working with insisted it was a fine movement of the wrist. I was really sure it was a fine movement between the thumb and index finger.
I love being right.
You see pill rolling in some folks with Parkinson's disease. It's often a tip off for me that I need to look for other symptoms to determine if I should be worried or if its just a nervous tic. Because its a resting tremor it's one that is often difficult for the patient to hide and will present itself during the Q&A portion of our visit.
Have a look at this article on how pills used to be made to get an idea of where the name came from. My favourite quote is:
Pharmacists could coat pills to disguise the flavour of the medicine, making them easier to swallow. Depending on how much the client was willing or able to pay, thin gold or silver leaf, calcium carbonate (to achieve a pearl finish), sugar, or gelatin could be used. Many of these coatings made the pills indigestible. As a result, they would pass through the digestive system whole, without delivering medication.
Sunday, July 21, 2013
My online appearance is more important than my physical appearance
I had a great time today reading posts and comments on Twitter about physicians' appearances.
Things I've learned:
1. Some docs really like this article from 2005 (!!!!) on the importance of dressing well for your patients. Remember it can take up to 3 years to publish an article so this data is from 2003 at the latest. Think track suits and Queer Eye for the Straight Guy.
Things I've learned:
1. Some docs really like this article from 2005 (!!!!) on the importance of dressing well for your patients. Remember it can take up to 3 years to publish an article so this data is from 2003 at the latest. Think track suits and Queer Eye for the Straight Guy.
2. The BBC would really like doctors to generally judge everything about their outward selves. This article looks at "scruffy doctors", overweight doctors, and doctors who smoke. They also acknowledge that many patients are expecting the white coated doctor to be male.
Which brings me to...
3. A separate discussion has been playing out today on Twitter about how young female physicians are perceived spurred by this blog entry. Female docs are often (VERY often) mistaken for nurses. Even after introducing themselves as Doctor SoandSo. I know I've blogged on this before but I can't find it. We are also assumed to be the assistant, the secretary. As an older than average resident, I was usually mistaken for the social worker or my pediatric patients' mother DESPITE wearing an ID badge and my stethoscope. One intelligent staff member asked me 6 times during my 2 month pediatric rotation to fill out the insurance forms for "my child". She was shocked every time that I was *still* a physician. I was once blocked from a code by the nurse who called me to it because she thought I was a family member (again, with stethoscope and badge).
While I was on rotations in other hospitals, I would carry a small bag with my "pocket" stuff. Pens, a Drug Pocket, my phone. Most "professional" women's clothing prohibits actually using pockets if they do exist. This teeny satchel was usually the scape goat in my mis-identification.
This is one of those issues that makes me a bit cranky. Have I told you yet about the preceptor who told me that it was perfectly reasonable to be mistaken for the social worker since "doctors don't have long curly hair, you can't expect to be taken seriously"? It makes me see red.
If, in real life, I'm mistaken for another profession or not a professional at all, based on my hair and my satchel, what must the medical world think of me based on my online profile?
Some argue that our online presence allows others to see our "true selves" (it's the basis for many relationships that start online). Social media (SoMe), plays a big part in my life. I'm in a tiny rural town, most of my friends are in different provinces. Without my online presence, I would be entirely isolated. My professional online presence is split between The Imposter and Dr. SoandSo. Maintaining my anonymity on this blog is important to my being able to use it as a sandbox for trying out ideas and ways of dealing with patients in a safe environment. As Dr. SoandSo, I have opinions on family medicine and its role among the specialties. As just me, I am on Facebook with my friends and family so I can watch my family grow up from a distance.
I'm seeing guidelines and suggestions about how docs (and everyone else) should behave online. It's true, many docs are illiterate in the ways of SoMe, but I think that they are aware of how to behave in a crowded mall. The same rules we learned in kindergarten apply.
- Share everything. Post your references so others can also be as smart as you.
- Play fair. Don't overload your online profile so that your friends aren't also visible.
- Don't hit people. Don't call them names. Maybe they have had a really bad day.
- Clean up your own mess. Untag any photos that you wouldn't want your mother to put into the family Christmas card.
- Don't take things that aren't yours. Credit any source that you use. You wouldn't want someone else prancing around in the sweater you took 3 years to make claiming they knitted it themselves. Our intellectual property is just as important.
- Say you're sorry when you hurt somebody. Apologise when you make a mistake and correct those mistakes.
- Wash your hands before you eat. MRSA y'all.
- Live a balanced life - learn some and think some and draw and paint and sing and dance and play and work every day some. Your online friends are interested in the new bottle of wine you found just as much as they are the new journal article that you found so fascinating. Share. But please don't overshare.
Truthfully, first impressions are just that. The patients who mistook me for a social worker trusted my ability to care for their medical needs. First impressions don't matter nearly as much as who we as health professionals truly are. How many times have you heard from your patients the story about the surgeon in his million dollar suit with no bedside manner? Could you possibly sleep well at night knowing that you had treated your patients in a way that would have put you in the corner during kindergarten? My online presence is as close as it comes to knowing the real Imposter and how she speaks with her patients.
Dress respectfully for your patients but act respectfully (online and face to face) for yourself as much as them.
Friday, July 5, 2013
Changes are coming in residency training
The CMA posted this morning that residency expectations will be changed by 2017. It will be competency based rather than time and exam based. In theory, this is already going on. You need to be recommended to sit your licensing exam by your program. If your program sees you as a resident at risk, they should not recommend you. From what I understand, this rarely happens, what Dr. Jason Frank in the article calls "failure to fail". Medicine in general has a tendency to pass students who should be re-mediated, or, kicked out. People are shocked that my school kicked 3 people out of our program, despite being a pass/fail school. So, sub-par residents can make it through to their exams missing essential skills.
My clerkship program was quite focused on our actions - for example, we all needed to deliver one baby vaginally, place 5 peripheral IVs, etc. etc. Students were not always able to complete the activities though because their residents scooped them all, their consultants didn't have time, or there just weren't enough patients. Fake signatures abounded, our teachers were willing to sign off when we were able to describe what we would do if given the opportunity. My exam in IM was meant to be hands on, but ended up being a seated conversation between me and my preceptor.
In my experience, preceptors who are not in academic centers are not great teachers and can be even worse at giving feedback. Many I've met choose to stay away from academic centers to keep away from the extra workload of teaching and research. For residency programs to have such a strong focus on competency and the improvement of those competencies, there needs to be a significant improvement in the training of preceptors, especially those who are based in the community and in rural settings. 4 years is an optimistic turn over time. Many of the docs I've worked with this year are holding me to the same standards they were held to 15 years ago in their training in a specialty other than family medicine. Getting those docs into this decade, into my specialty, will take some effort. It will take much more to get them in line with an entirely new way of completing residency.
If however, this is based on objective observations by a small number of mentors/preceptors who can watch the resident progress from tadpole to frog, it will be a step in the right direction. These observers will need to have their own mentors to help them differentiate where a new resident should be versus a senior. The proposed evaluation program assumes that those evaluating residents will be able to make these distinctions. Unless you have experience with many residents at various levels, knowing how a resident is performing can be tricky.
Most concerning to me though, is the dependency of this type evaluation on numbers of patients. I've been worrying about this since I noticed the rising number of learners coming behind me while we are rushing patients out of hospitals. Despite taking on extra call shifts, totally ignoring PAIRO's rules about hours working, and leaving my cell number for all attendings to call me with juicy cases, at the end of my residency I have spaces in my skills log that are empty, experiences my residents told me I would get after clerkship. If I was graduating from residency in 2020 with the bad luck that I've had for catching cases that are on the relegated list of "must do's", it would take me extra time to finish. Which is fine. But it also means that I'd be taking those vaginal deliveries from junior residents and clerks, because shit does flow downhill.
In an ideal world, this is a great proposition. I try to be optimistic but my experience with community docs having something extra to do makes it hard. I expect the community and rural programs to lose preceptors when their responsibilities change.
My clerkship program was quite focused on our actions - for example, we all needed to deliver one baby vaginally, place 5 peripheral IVs, etc. etc. Students were not always able to complete the activities though because their residents scooped them all, their consultants didn't have time, or there just weren't enough patients. Fake signatures abounded, our teachers were willing to sign off when we were able to describe what we would do if given the opportunity. My exam in IM was meant to be hands on, but ended up being a seated conversation between me and my preceptor.
In my experience, preceptors who are not in academic centers are not great teachers and can be even worse at giving feedback. Many I've met choose to stay away from academic centers to keep away from the extra workload of teaching and research. For residency programs to have such a strong focus on competency and the improvement of those competencies, there needs to be a significant improvement in the training of preceptors, especially those who are based in the community and in rural settings. 4 years is an optimistic turn over time. Many of the docs I've worked with this year are holding me to the same standards they were held to 15 years ago in their training in a specialty other than family medicine. Getting those docs into this decade, into my specialty, will take some effort. It will take much more to get them in line with an entirely new way of completing residency.
If however, this is based on objective observations by a small number of mentors/preceptors who can watch the resident progress from tadpole to frog, it will be a step in the right direction. These observers will need to have their own mentors to help them differentiate where a new resident should be versus a senior. The proposed evaluation program assumes that those evaluating residents will be able to make these distinctions. Unless you have experience with many residents at various levels, knowing how a resident is performing can be tricky.
Most concerning to me though, is the dependency of this type evaluation on numbers of patients. I've been worrying about this since I noticed the rising number of learners coming behind me while we are rushing patients out of hospitals. Despite taking on extra call shifts, totally ignoring PAIRO's rules about hours working, and leaving my cell number for all attendings to call me with juicy cases, at the end of my residency I have spaces in my skills log that are empty, experiences my residents told me I would get after clerkship. If I was graduating from residency in 2020 with the bad luck that I've had for catching cases that are on the relegated list of "must do's", it would take me extra time to finish. Which is fine. But it also means that I'd be taking those vaginal deliveries from junior residents and clerks, because shit does flow downhill.
In an ideal world, this is a great proposition. I try to be optimistic but my experience with community docs having something extra to do makes it hard. I expect the community and rural programs to lose preceptors when their responsibilities change.
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