Monthly Archives: April 2015

I graduated from college with a degree in Economics. This is where I came across the term, ‘externalities’. The official meaning of this is the cost or benefit a third party receives from an activity. For example, a negative externality of alcohol use is increased motor vehicle collisions as a result of impaired driving. For the purposes of this post, I see it as an unintended, uncontrollable consequence.

As I’ve mentioned I recently began shadowing physicians in the clinic, beginning my long journey to managing patients again. I usually follow with an Attending Physician, a physician that has already completed residency, but sometimes I will follow a senior level resident. Last week, I had the privilege of being matched up with a resident by the name of Abigail Urish (or Abbie). I met Abbie when she was an eager, bright-eyed intern. She is now a third year resident, elected chief, and ready to embark on her own in only a few short months. I have always admired her, not only for her obvious high intelligence and willingness to learn, but also for her optimistic disposition, finding the light in the dimmest of situations.

We entered the room for a patient encounter together. There are times when the moment you enter the patient’s room, you can sense that something’s amiss. Perhaps it is the look in the patient’s eyes, or maybe it is from the way they are sitting, or possibly a combination of factors, but when we entered her room both Abbie and I could sense her depressed mood.

I know I have written on the topic of depression several times before, but what Abbie told her was very poignant and struck a chord with me. During the encounter, the patient told us of several of the hardships she was enduring (i.e. loss of custody, a dispute with her child). Abbie was then faced with the daunting task of describing depression in less than the 15 minutes allotted for each visit. Abbie told her that, “Depression is a hard entity to treat, because unlike so much else in medicine, with Depression there are no blood tests or x-rays we can obtain to aid us in diagnosis. Also, response to treatment is so variable and really depends on the individual patient. My thought is that Depression is very much related to how we react or internalize external situations. There are some who face incredible hardships, yet are able to see the silver lining in any situation. You just told me about some very hard events in your life, but you also mentioned some bright happenings too. Unfortunately, someone who suffers from Depression zeroes in on the bad or tough situations. Just to give you an example, if someone takes a test with 100 questions and gets 99 out of 100 right, a depressed person will only remember the one question they missed as opposed to the 99 they got correct. The medications and therapies we prescribe can only serve to help with this outlook. We can’t control much of what happens to us, but what we can change is how we react.”

The more I thought about it, the more I realized how right Abbie was. We as a society are obsessed with trying to control or modify situations that are thought of as immutable. Examples of this are littered throughout medicine: risk factors for developing a disease are generally divided into modifiable and non-modifiable risks. The idea of attempting to alter these modifiable risk factors is drilled into our heads from the first day of medical school. I am by no means saying that these external, changeable factors should be ignored. For example, stopping someone’s smoking habit can have repercussions throughout their life. But I believe that too much of our focus is placed on factors beyond our control. All of us receive a ‘raw deal’ at some point in our lives, and while we cannot control many of these situations, we can change how we face these challenges.

When I was applying for medical school, the interviewers often posed the same question: Do you see the patient-physician relationship as more akin to a parent-child dynamic or to a partnership? While it was always clear which answer the interviewer sought to hear, I have come to realize the importance of this idea.

Medicine, as old as it is, would cease to function if it were treated as anything but a partnership. Yes, the management opinions of the clinicians are rooted in years of medical training and knowledge, but in the end the plan of action only comes to fruition after deliberation from both parties.

One of the perks of this job is that I’m often consulted in cases where my medical knowledge is needed. Several months ago I was introduced to ‘Erica’.[1]  Erica had undergone surgery to remove an Epidermoid Tumor. Unfortunately, she was experiencing several post-operative symptoms, one of which was fever with headache.[2]  In medicine, there are certain symptoms called ‘red flags’; these are symptoms that clue the clinician in that something worse is going on (for example, if someone were to tell you that they have chest pain that feels like ‘tearing into the back’; this is a red flag for a condition where your aorta is literally splitting). In Erica’s case, fever with headache following brain surgery was a red flag for meningitis (an infection of the central nervous system). As was prudent, she promptly called her Neurosurgeon who advised that she go to the Emergency Department (ED). She went to the ED where the physician deemed that she did not have an infection, and subsequently discharged her home with instructions to see her primary care physician (PCP) in the coming days. Her PCP obtained some further testing and suggested she return after several weeks. Here is the problem (and why I was consulted): she was still having fever with headache. Was the diagnosis of meningitis missed by her physicians?  She questioned the knowledge and decisions of her clinicians so much so, that she even considered returning to the ED at a time that she knew that her previous ED physician wouldn’t be there. She also considered seeing a different PCP for treatment. I was asked what her next step should be. My response (via e-mail) is what follows:

Hi Erica!

These are all legitimate concerns that I’m glad you brought up.

The bottom line is this: I agree that accepting care without question is not the optimal way to practice or receive medicine. It is a partnership where each party has at least some trust in the other party. If this balance is shifted too far in either direction the result is a negative outcome for the patient. Why is this relevant to you?  In your case we should believe, to a certain extent, that your physicians are acting in your best interest. This is by no means a blind approval of care, but in order for this relationship to persevere a certain level of trust must be maintained. If you do not trust your caregivers then you should sever ties with each of them.

We each have roles in this situation: both Marcie[3] and I are to serve as objective observers for your sake, and interject with our clinical knowledge when we see fit. I tend to look at situations as a group of alternatives: for you this is what I see: option 1. Continue the current path, meaning doing nothing, option 2. Stop seeing your current physicians and find new caregivers, perhaps getting a different outcome. And 3. Openly question your current path to your caregivers in hopes of forging a new one. Personally I would still go with option 3 but one of the great aspects of medicine is that you have the choice. 

Best,

Chris

Medicine is a partnership, a partnership with the goal of achieving optimal health for the patient. When this partnership struggles mistakes occur. This ‘struggle’ could be (and usually is) the result of poor communication from one or both parties. If, for example, you either do not trust or blindly follow the opinions of your physician, then this ceases to be a partnership and you will ultimately be dissatisfied with your care. If the clinician does not trust the patient in any way, or he/she does not effectively communicate the rationale behind his/her decisions, then misjudgments inevitably ensue.

Even though this began in my life as a rehearsed interview answer, it means so much more to me personally, and I hope for you too.

[1] For the purposes of this article, I will conceal her true name.

[2] For anyone involved in medicine, alarm bells screaming ‘meningitis!’ are ringing.

[3] ‘Marcie’ is a neurosurgery Physician’s Assistant that was also consulted on the case