Making patients responsible for their own health

Something we talk about a lot at our hospital is that we expect our patients to take control of their own health.

You're out of breath and coughing like crazy? You should choose to stop smoking.

You've had a headache for three weeks and haven't tried Advil yet? Seriously? I have no words for you.

There are ads everywhere reminding patients that they need to be screened for various cancers. Patients should take responsibility for initiating contact.

Once you make contact, Advil didn't work or want to quit smoking? I'd LOVE to help. But honestly, if I'm pulling you by your nose to take care of yourself, you're not going to like it and I'm going to lose interest. Patients who come in wanting to find out what they can do to prevent constipation or to lower their cholesterol make me glow. I love teaching my patients.

An issue that comes up, as it does with so many patient centred practices, is time.

I try to get around this by building up an idea then giving my patients homework. Next visit, we review what happened. Getting patients to buy in is sometimes tricky but I find it gives us a goal to work towards in our visits, especially those with chronic disease.

I wonder if preparing a journal for patients with a specific disease to work through might work better. This article suggests journaling to improve compliance for exercise in the depressed, and offers suggestions for topics after walks such as "how do the trees around you look?" Maybe having a set list of mini goals to achieve would improve compliance.


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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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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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"Things will get easier, people's minds will change, and you should be alive to see it"

I know it's cliche, but our media is not doing teenagers any favours.

Ellen's talk about the teen suicides in the US that are following bullying is powerful and long overdue. Not just by her, but by adults and media in general. Everywhere they look, media is focused on teens and telling them what to do, how to look and who they are expected to be. Bullying isn't just taking place by other kids targeting children kids who are different, who may or may not be gay.

Idiots on the net are suggesting that the kids who are killing themselves to escape the bullies were mentally unstable before the bullying began, that being gay is a form of mental illness. They clearly forget how hard it is to be a teenager. It's incredibly difficult to keep your wits about you while figuring out who you are and dealing with surges of hormones. There are few teens who are mentally stable to begin with. Add bullying to the mix and it's surprising there are more episodes of suicide than there already are.

I was one of those kids who was teased about being gay before I had discovered for myself that I wasn't. To me though, this teasing meant nothing because I didn't see anything wrong with being gay, as long as they didn't call me fat or stinky I was OK.

Again, movies, TV and magazines tell us that if we do things perfectly -by wearing the right makeup, dressing in tight clothes, sleeping with whoever we please, drinking alcohol and still being brilliant at school, friendly, athletic and thin - we will have more friends than we know what to do with.

No pressure.

Hard to imagine why kids struggling to define themselves are struggling so much. Each teen is fighting this battle and has a difficult time recognizing that they have peers fighting similar battles. It results in them feeling isolated and ignored and trying to find a way to be seen. They become bulimic, goth or emo; buy crates of makeup and perfume; dress like sluts; slowly self destruct.

I've spent a few weeks with the child psychiatry team and these messages and how teens deal with them have been at the forefront of my mind. There isn't a fast solution to the problem which seems to be systemic. All I can hope for is a change in the content of the messages being broadcast to our youth.

Imagine you're a ten year old kid. Your thinking is still very concrete; sarcasm and shades of grey are completely lost on you. If someone tells you that you are too chubby you believe it. If someone tells you there's an obesity epidemic - that being fat is unhealthy - you believe that too. Then you start to pay attention to other messages from media, school, peers and adults. Foods low in calories, low in fat and sodium are healthier choices. Empty calories that you get from foods like the pop and chips you enjoy occasionally with your family are not good. Rules for eating and exercising begin to be formed in your head, all because you want to be more healthy.

Congratulations, you now have an eating disorder. Not because you think that you are too fat and need to look better, but that you are unhealthy and want to become healthier. Without countering the restrictive messages with messages of balance, enjoyment and the importance of certain nutrients like fat, this ten year old can become an eleven year old who is so malnourished, has a heart that is so wasted of muscle its SA node no longer function and an EKG tracing shows a junctional rhythm. The only option is to put this child into the hospital, provide him with nutrients at a rate that will not cause refeeding syndrome, and teach him the way to feed himself in the future - a balanced approach to be healthy.

Adults and especially health care professionals have a responsibility to keep the messages kids receive safe. Ellen is right. This is a crisis.

Diagnosis, Sesame Street

Silly, fun.

I always thought of The Count when studying OCD. Nice to know I'm not alone.

you can have ice chips

It always seems so strange that patients are so grateful when we let them eat ice chips, pee without a catheter walk with the freedom of no iv's. On my psych rotation we handed out smoke passes to patients who were well behaved.

If patients make enough urine, out goes the foley.

There is such a huge amount of power given to the docs over their patients' smallest and most basic bodily function. Things everyone takes for granted.

It's exam week

I'm disappointed with how little actual school work/learning I've had time to do this year. It's clear that when I have the time to study and stay on top of the work load (eat all those pancakes) I can do very well.

We had a one week course in Emerg/ICU care this semester. I stayed on top of the material and feel like I killed the exam. Yes it's just one week, but that just meant I was able to stay on top of the work. What makes this win extra scary though is that the rest of the class seems to feel that they did not do well on the exam.

The other three courses this semester though, will not go as well. I'm desperately choosing which weeks I will study. Weeks! Not just lectures or parts of lectures I feel are less important, entire weeks!

We had our OSCE last week and despite studying for the past 2 years and feeling pretty prepared for it, I was knocked off my game a couple of times. It was fun but also, as I said to the examiner for the ankle exam, fully humiliating.

Our school has a pass/fail system so that as long as I make my 60%, I'll make it through to clerkship. For the OSCE, we just need 60% of 60% of the stations. But, I don't want to be the doctor that barely made it through med school. I don't want some doc in administrivia hell looking for the last 1/2 % so that no one has to hold my hand through remediation in the summer. I want to do well in clerkship and need to start making studying a priority in my life. Starting.....NOW.

Don't throw stones

We're coming up to our last week of psych. It has been a relaxing block so far. I was able to get through one week of notes in an afternoon. That never happens for me. I've spent an afternoon on 3 renal lectures.

This is when MedStudent-itis has shown up. I have gone through notes diagnosing my classmates, my family, my partner, my past partners and me. It's shocking how much mental illness there is near me.

This block has been eye opening as far as how my classmates view mental illness. It's clear that the stigma attached to it is alive an well in our ranks. I hope to continue to advocate for those with mental illness.

During our CBL session last week, I made a comment to the effect that patients who don't take their meds are much less likely to get my sympathy than those who do. I was shot down by the other members of my group. I can't remember what their argument was, I'm sure it was brilliant.

What I did think about for a while after was that I am just as guilty of not taking care of myself. Despite counselling patients and family to eat well, I still eat donuts, drink too much coffee. I haven't been to the gym in a couple of months.

I was comfortable throwing stones in this glass house of mine. And very glad I've recognized yet another prejudice I hold.