All of Life's Important Lessons

Everything you need to know comes from the movie Princess Bride.

Here, Buzzfeed shows us some of the funnier lessons.

A mom blogs about what Princess Bride taught her about autism. I love her take on it and think it's applicable to everyone, not just those who love someone with autism.

My favourite lesson is the first:

1.  Affection doesn’t have to mean saying I love you

Reading a story to someone who’s sick in bed, saying “as you wish” or playing rhyming games that annoy your boss... there are many more ways to show love than just those three little words.

I've found a new reason why this is important. Many patients that I have are stubborn. Shocking I'm sure. Today I told a woman that because she refuses her daughters' help, it's like she's not letting them show her how much they love her.

I may have just taken the guilt trip to a whole new level.

Med Students are Biased Against Obese Patients

I want to pull out the original study, but from this article it looks fairly well done.

Essentially, 3rd year medical students in North Carolina were shown drawings of a thin or obese person and the time to associate positive traits was measured. 1/3 were moderately to severely biased against the obese diagram.

This isn't shocking - we've seen it before with practicing docs.

When planning my education objectives in residency, I often hear warnings about recognizing that there are things I know I don't know, things I know I know, things I don't know I already know and things I don't know that I know

Something I like here is that they point out that we need to find a way for students to be aware of their bias. This is a tricky thing to teach since it often falls into the category "what we don't know we don't know".

Teaching students to recognize bias must be a lot like doing psycho therapy - challenging the thoughts that go on behind our actions. It may be that teachers acknowledging their own biases during case presentation may make it second nature for students to include acknowledging bias in their own work. Providing a positive role model to med students is important. We know that clerks are sponges for behaviours they see on the ward. It seems reasonable that positive behaviours can be picked up this way as well. Possibly, we need to devote class time to learning about distorted thinking. We discuss the biases which are inherent in most medical research but often miss the bias we bring to our everyday life.

"If doctors assume obese patients are lazy or lack willpower, they will be less likely to spend time counseling patients about lifestyle changes they could make," he said. "Doctors also may be less likely to recommend formal weight loss programs if they assume their patient is unlikely to follow through. "

Miller said bias might also make doctors less effective. "If a patient senses his or her doctor doesn't like them or doesn't respect them," he said, "that will damage the trust that is key to an effective patient-physician relationship."

This is an issue for more than just obesity. We see this in substance abuse and alcoholism as well. If we don't ask, don't offer help for change, we are cheating our patients.

More importantly, if we allow our biases to lead us, we are teaching the next generation of docs to do the same.
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Suicidal Ideation

We are taught to screen for patients who want to kill themselves. Mnemonics such as SAD PERSONS offer us structure for listing risk factors that put us on high alert.


Often I hear things like "what's the point in taking my medication when it's only prolonging the inevitable?", or "I'd rather have hair than live the extra year that chemo will buy me." We call this passive suicidal ideation. People who do not plan to kill themselves but wouldn't mind if they were dead.


Shocking to me today, was the patient who calmly told me his plan for suicide. He has spent months researching a clean, pleasant way to die which he believes will not scar his family. He has even invited his brother to sit with him as he goes. This is a man who may not have long to live and wants to leave the world on his own terms, in the manliest way possible. Being eaten alive by wild animals would be preferable to the slow death his COPD promises.


More shocking to me, was the way I dealt with this news. I didn't miss a beat and continued to ask him to explore the idea.


Now that his plan is in the open, psychiatry needs to be involved to prevent him from preemptively taking his own life. I find myself questioning the futility of that, but will honor my oath and do all I can to keep my patient comfortable and alive as long as I can.


The psychiatrist may lift the Form One because the patient is reasonable.


In the mean time, I'm researching how to get an angry grizzly bear into the Resp unit with no one noticing.
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The patients you think about

Have a look at this article. I've been following the blog on twitter and learning quite a bit. This case in particular raised my shackles a bit.

Similar aged woman presents late at night to my ED with a week of deep, dull chest pain. No risk factors. Her ECG was beautiful. D-dimer was negative. OE viral URTI. No improvement with ibuprofen. I was reassured and sent her home to follow up with her family doc ASAP.

Even now, seems reasonable.

I recognize though that I'm someone who suffers from "Nah, it can't be." I know in this case I did all the investigations I would have done for a 45 year old except calling radiology to get a CXR.

Having cases like the one described in the ECG teaching help me to keep perspective. I think we need to share. These odd cases so we remember that not everything we learned in med school was true.

The trick, as ever, is protecting patient privacy while expanding the knowledge base we have available.
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This is NOT a 2 am consult

I'm always afraid of being wrong and making a stupid mistake in front of colleagues. I think it's fairly common, we all want to be seen as competent care givers. We never want to admit that we don't something but when our patients need us to 'fess up about our lack of knowledge, we will, and call a friend.

Working in a small ER means that rather than having in house specialists I can bounce questions off of in the middle of the night, all my specialists are elsewhere in hospitals where they are expected to be allowed to sleep from 11pm on because they'll be on call all weekend. It takes a lot of guts to call after midnight.

I'm sure you can see where this is going.

I've seen a lot, but I haven't come close to seeing everything. I try to extrapolate from what I do know to what I'm seeing in front of me. Given what I saw the other night, and what I know from other similar structures, I was going to need help. Apparently I should have known better and that I didn't need help.

I still feel like I did the right thing. I had a patient in front of me with unbearable pain. The resources in front of me where not at all helpful, though I could have looked for the procedure on youtube... I called. I got snarked at. I also got the info I needed and my patient left free of pain.

Since this blog is about making me a better a doctor, what would I do differently next time?
1. look in even more basic books than I was, something like Tintanelli's.
2. YouTube the procedure.
3. Start my consult (if I still decide to call) with "I'm not sure this is a 2am consult, but my pt is in quite a bit of pain...".
4. Take a breath and put everything in context. I frequently let my nurses guide my care. I trust them to know what to do and very often, that's a good call. But sometimes, I need to listen to my own brain and cut them out.
5. Work out how I would do what I need to do - get the patient into position, get the equipment I need in position. There's something about going through the steps first that makes a procedure easier to do and less scary as well.

Eeyore

I convinced a 5 year old girl this week that Eeyore isn't sad, he's dysthymic. Hearing a wee girl without front teeth say "dysthymic" is awesome.


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Cards Against Humanity

Today was the first of three days of my family medicine licensing exam. It was the short answer management problem day, 3 hours in the morning, 3 hours in the afternoon with an hour for lunch in between.

I had room in my bag for either my notes or my box of cards against humanity game.

I made the right choice.

Playing a silly, irreverent and occasionally dirty game was the perfect mid exam break.


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