Archive for category Medical Education

Is it serious?

A couple of things happened this week that inspired me to write.

My little girl got an infection. Oh, the irony. She was quite cute about it though. It started out as a mosquito bite or something like that – it was itching her at any rate. Little tyke was trying to put steroid cream on it to stop the itching. It probably would have worked if she hadn’t picked up the toothpaste instead. (She’s only 4, by the way)

So a day or two later and she’s got a red, painful, spreading infection on the back of her foot and I’m cajoling her to take oral keflex (first generation cephalosporin, good for group A strep and staph). She’s got a fever, vomiting, diarrhea…and we start worrying whether it’s an antibiotic side effect or the infection. It quickly becomes clear though that it’s the infection as she keeps down more of the keflex and everything starts to heal up.

As we sat brushing the hair of her My Little Ponies a day or so later she asked me “how did the infection get in there?” I pointed out the little bug bite and explained that it was a hole in her skin that let the bacteria in. “Oh, ” she said, “that’s dangerous.” And she went back to playing.

But yes, yes it was. Untreated staph and strep infections land kids in the hospital all the time. So was this a benign minor bug bite, or did I manage to avert catastrophic sepsis in my offspring?

This morning, quite by chance, my mum called for a chat. She asked me what I was doing – I explained I had to go into work for a consult. “Oh dear, ” she said, “is it serious?”

I caught myself just before I laughed out loud and said “No, not really” when I remembered what happened to my daughter this week. Just what was a serious infection anyway? Doesn’t that depend on your point of view as much as the organism, site of infection, and antibiotic resistance pattern? What is, to me, a relatively routine consultation, is at it’s minimum a human being whose body has been invaded by a microorganism which is attacking and destroying it from the inside! This is someone’s child whose health is not just in jeopardy but whose health has already been compromised by the fact that there is an infection there.

There are social implications to an infection like that – the stress and discomfort of a hospitalization, time away from family, and time off from school and work. This is a Life Event that will never, ever, be forgotten. For just a second, imagine yourself or a family member suddenly admitted to hospital and requiring invasive procedures for an uncertain cause. For some of my readers, I know they don’t have to imagine!

So we as clinicians need to remind ourselves of this from time to time. We must be wary of being complacent in what we see and mindful of how it’s perceived to the patient and their family. If we are confident in what we’re dealing with it behoves us to explain to patients and families why we think the treatment will work and how we expect things to go. Just because it isn’t end-stage cancer doesn’t mean we should ignore the same rules of breaking bad news – explain with clarification, give yourself time, give them time, allow for questions, provide reassurance without false hope and set expectations…there’s a list somewhere. Don’t pooh-pooh “routine” questions, because for that person they’ve never had to ask them before. Don’t belittle their experiences – pain, anxiety, anger. They’re all justified, in the moment, to them.

So to answer my mum’s question, yes – it was a serious situation. But the kid’ll be fine.

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Why I practice patient-centered care – and why you should too.

The simple reason why I practice patient-centered care is that it’s better for the patient. But before I go into the details of that, we need to step back a bit.

Firstly, I’ll clarify what patient-centered care isn’t. It isn’t pandering to a patient’s or parent’s wishes and doing whatever they want, as a mere provider of healthcare. That is patient-LED care. I don’t think that’s always a good idea – most people after all have NOT gone through medical school and several years of practical training (something like 20,000 hours of supervised patient-care in my case) in order to make informed decisions on their health. Even though the Internet has leveled the information playing field considerably, you still have to know how to interpret that information in the appropriate context and with the correct background knowledge. There are places where patient-led care does play a role, but it is quite distinct from patient-centered care.

I define patient-centered care as “practicing medicine taking into account the patient’s concerns, expectations and understanding.” You may not find that definition anywhere else put quite like that, but to me it makes sense. It also follows a three-step process of “discover, validate, address” that I iterate through an encounter so that by the end we’re all on the same page.

When I was in medical school I was lucky enough to be asked to pilot a new curriculum element called Preparing for Patients (my sole legacy to Cambridge University is that I was the first to coin the abbreviation PfP – which obviously was no great intellectual feat, but I think worthy of a footnote in the annals of history). I was not yet seeing patients on the wards, and felt quite unprepared having spent much of my work experience during high school in various labs – examining things like different plant species, fiber glass tensile strength and drug purity.

PfP was an intensive program back then, a couple of weeks of daily sessions where we explored our own fears and thoughts on medicine and patients, then got to experience and practice actually talking to patients about their illnesses. The real beauty was in the use of standardized patients: actors and actresses who could give a consistent experience to everyone and respond to questions, even off-line, in character. I got to tell someone they had cancer with a 50% mortality several times before I actually HAD to tell someone they had cancer (which as it happens was at 2am one morning on call as an intern, by myself – that’s deserving of a blog post all for itself…). The experience was invaluable, and provided a toolset of behaviors, questions and actions (71 skills all told) that I could bring into play when I needed them during an encounter. I got to try out this new-fangled curriculum and provide feedback to the course creators on the process and content.

The course itself still stands, albeit in a greatly modified form. It is now a fully integrated part of the Cambridge curriculum, from the first year of pre-clinical science, and those 71 skills are the benchmark by which all Family Medicine (aka General Practice) docs in the UK are assessed for their board exams.

What I learned from that was invaluable – it turns out that talking to patients is a lot more than simply asking questions about their symptoms. Patients are people – they have preconceived ideas about their illness, they have worries, they have ideas on what needs to be done. Sometimes they’re wrong, in which case our job is to educate and reassure (or sometimes not…), but often they’re right and our job is to help get things done. I learned that illness (what a patient experiences) is different from disease (what a doctor treats). A tension headache is an awful illness, but a minor disease that the doc can do little about beyond over the counter pain meds. High blood pressure on the other hand usually has no symptoms whatsoever but serious effects on the body so that we want to treat it. The question was posed – how do you convince someone to treat something that isn’t making them sick right now?

What I also learned was that there was actually research to back up this approach – patient complaints and concerns about medical care (including well over half of all malpractice lawsuits) usually stem from communication failures or unresolved issues. Issues often were unresolved because the doc either didn’t allow the patient to bring it up, or didn’t explain things fully. Patients do not tend to bring up what medics would consider the most important issues first – for all sorts of reasons – and yet they are often cut off early in the rush to get them out the door and see the next one. Something as simple as asking “What are you concerned about?” early on in the encounter can save a ton of time, as you can focus in on what they’re most worried about right away. (Of note, you’ll get different answers asking that than if you ask “what are you worried about?”, which I find fascinating…) Making someone feel at ease is one way to encourage them to talk about embarrassing symptoms or scary possibilities, and there’s an entire skillset devoted to building rapport and trust for precisely this reason.

My general approach is the “discover, validate, address” thing I mentioned earlier. Discovering concerns may be as simple as asking them what they are, but there may also be subtle hints – a family history of cancer, a perseverance on a particular topic or symptom, facial expressions and other body language. You may focus in on something you notice, or use open-ended questions to hear things in their own words. It may be an ongoing process through the encounter, but ideally you get most of it done early on to avoid the “by the way Doc…” question as you’re wrapping up.

Validation isn’t simply agreeing with them – after all, people often get misled or misunderstand things. Validation is acknowledging that from their perspective what they’re feeling about something is entirely appropriate. They may be angry that their prior Doc didn’t treat symptom XYZ, but if, medically, it didn’t need treatment, then their Doc did nothing wrong. But if I can commiserate with them, ask about how it’s affecting their daily life, explain that this kind of symptom isn’t one we can treat – this often goes a long way to fixing the issue.

Addressing a concern may be already covered by just acknowledging its existence, but may require an explanation of why treatment or testing isn’t necessary, or it may require convincing someone to undergo a treatment plan that they’re really not all that keen on! It’s important to offer options – there is always the *option of doing nothing*, even though that’s not necessarily the best option. It’s critical to explain YOUR thinking about something – admit your biases, your own concerns about the patient – they’re more likely to follow through on your recommendations if they know why you’re sending them for blood work, x rays or a cardiac stress test – or asking them to pop a pill every day for the rest of their lives!

What this approach does is help the patient have more control over their medical care than an old-school paternalistic approach, but with more education and understanding than a patient-led approach. If you train doctors to talk to patients this way an amazing thing happens – the patients do better. Improved communication can improve management of diabetes and blood pressure, but also reduce followup visits and tests, lower reported pain levels, and some surprising things like reduced costs in the ICU. Others have already listed the main references. To me this proves two things.

Firstly – there are clearly deficits with doctor-patient communication that need to be and CAN BE addressed.

Secondly – YOU CAN TEACH COMMUNICATION SKILLS. I cannot overemphasize this enough. One of the largest myths in medicine is that you either have a good ‘bedside manner’ or you do not, and if you don’t you’re stuck with it. That simply isn’t true. You CAN teach medics of all levels – from medical students to consultants – new skills and demonstrate changes not just in their behavior, but in their PATIENTS’ behaviors. This is an astonishing finding, and the skills can persist for years. The only thing more astonishing than this finding is that we’ve known about it for decades. Communication skills are being given greater emphasis in medical school these days, finally, but testing is haphazard and unhelpful a lot of the time (feedback 3 weeks after a standardized encounter is nowhere near as helpful as an immediate conversation and a chance to do-over the visit) and training is often limited to lectures rather than structured practice sessions. It is difficult to teach it properly, and it is certainly difficult in an area traditionally taught through lecture format, and which is increasingly moving towards online self-directed educational formats. Carving out a 1-2 hour block of time every week to sit down in small groups with a trained facilitator and one or two trained standardized patients is what’s probably necessary, but I doubt many course organizers think that they’re able to do that – my argument would be that we need to find a way to make it happen, not that we avoid trying because it’s difficult. I am living proof that you can take someone who honestly was pretty socially inept and turn them into someone who can not only practice patient-centered care, but teach it to others. Throughout my residency and fellowship I led a group of child-life specialists, Residents and Attendings in weekly sessions with the pediatric clerkship students teaching a modification of the Calgary Cambridge Guide.

One common criticism about teaching patient centered care or communication skills is that it somehow detracts from the teaching of “real” medicine – the mass of signs, symptoms, risk factors, tests and treatment options that we basically have to rote memorize, as well as the practical application of all that knowledge with real, sick patients. My counter to that is: who says the two are mutually exclusive? You can learn medical facts during the practice sessions, you don’t need to know them beforehand. You can integrate the two aspects of medicine – and in fact you probably need to integrate them or else risk maintaining the mental block between “real” medicine and “communication skills”. Real medicine relies on communication skills to elicit a history and convey a plan – how else do you think this can be achieved? Telepathy? Flash cards? Who says you can’t run a code in a simulation then afterwards have the “breaking bad news” simulation with the manikin’s “relatives”?

And finally, doctors that have a disease-focused approach are more likely to experience patients as “difficult”, and those patients are more likely to have additional (unnecessary?) visits, than if the doctor had a more patient-centered approach. Patient-centered docs are happier docs.

So, to me, effective communication skills are an absolutely integral aspect of patient-centered care, and patient-centered care is a way to dramatically improve patient outcomes. These skills can be taught, and I argue they should be taught if we truly want the best for our patients.

If any readers of this actually do rotate through ID with me, remind me to discuss the process of an encounter as much as the content…I tend to forget!

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The redundancy of being called a “Medical Educator”

Incredibly, since I have been in my new position for over 6 months, this morning was my first lecture (but I use the term loosely) to the residents here. It was ostensibly on “infectious rashes and infestations” – but I entitled it “Nasty skin infections – cos there really aren’t any nice ones”.

It was apparently well received.

I have a knack for teaching. I’m not saying that because I think I have a knack – other people have told me so. I have various awards to show for it. I have people ask me to teach, and I assume it’s not just to hear my awesome accent. It has a history going back to high-school where my friends would ask for help with their homework. I had the annoying habit of not giving them the answers – rather I would try to help them figure it out for themselves – responding to their questions with questions of my own. I don’t remember whether I did this out of a sense of mentorship – the benign guidance of a sage helping them to reach their potential – or out of sheer bloody-mindedness and for my own amusement. I do know I simply didn’t think it was “fair” that I had to figure it out for myself but they wanted the answer simply given to them. I can’t blame them – we all want that at some point.

In medical school I found myself struggling in a competitive, highly academic and esoteric system which I was pretty unprepared for. I remember writing a scathing review of the teaching I had received there for my college magazine. I “dropped out” of one tutorial class to do self-study instead, and brought my grade up two points as a result (on a 4 point scale, that’s not bad…). I laid down the mental framework for how I wanted to be taught, and applied that to others where I could. I was lucky to be asked to supervise (teach, in Cambridge lingo) genetics and virology to two of the university colleges for two years. Ironically I found myself as a flawed part of the very system I had complained about – flawed in that I was teaching without any training in how to teach!

It was in my residency however where I really found a role for myself in teaching. My wife tells me that I “like telling people how it is”. She may be right. In any case, there are ample opportunities for teaching medical students, junior residents, peers and colleagues during the years that you yourself are getting educated and trained in medicine. I developed my own style – honed through trial and error, practice and observation. My research years had taught me a lot about how to teach and how NOT to teach effectively – and also removed whatever fears of public speaking I might have harbored. We all know that “teachers teach how they were taught, not how they were taught to teach”, but I made a conscious effort to TRY to teach using techniques that I knew to be effective, even if I hadn’t experienced them directly. I cherry-picked those I liked and adapted them to my own personality.

The techniques weren’t all that became developed – my repertoire of content grew and was refined. For most of the topics I was asked to teach about I got to the point where I could grab a pen and paper, or whiteboard, and put together an interactive case-based 1-hour teaching session with no notice.

After today’s success I thought a little about my role as a medical educator, and I remembered something.

Doctor. We all know what it means. Or do we?

It means “Teacher“.

The word “Doctor” has been hijacked by the medical profession (and other related careers), where in fact it was intended to mean someone with sufficient learning in a subject area to teach others. Technically in fact, most medical degrees aren’t “Doctorate” level at all, since they are “first degrees” in medicine, regardless of whatever degrees a person may have in another subject. My own medical degree reflects that: MBBChir, Medicinae Baccalaureus, Baccalaureus Chirurgiae – Bachelor of Medicine, Bachelor of Surgery. An MD in the UK (and almost everywhere except the US) is a true post-graduate degree with a research dissertation.

Ironically the medical profession seems to have forgotten that. Medical education in the US is an oft-neglected role, poorly reimbursed, run by those with a passion for teaching while feeding off the table scraps that their procedure-driven peers feed to them through the teaching hospital income. Until recently, there were few real incentives to teach or contribute to medical education – promotion and bonuses were linked to clinical revenues and research grant dollars. I am fortunate to work in one of the (apparently) few places that does place a value on medical education such that I can use it for career advancement rather than a hobby in my spare time. People go into medicine for all sorts of reasons – to help people, to heal, to make money, to do cool procedures and surgeries – but I doubt very many go into medicine to teach.

And yet they carry the title of “Teacher”. My own career track is that of a “medical educator” – which seems to me to be a redundant phrase, if you think about it. The fact that we have to label medical educators as something special shows how we have drifted away from the true meaning of “Doctor”.

To go back to our roots, we should ALL be educators. Every year there is a wave of students leaving their education and entering training, and a wave of residents leaving training and entering the real world. These men and women need guidance. Beyond the academics and pearls of wisdom, they need mentoring, career and business advice, insight into work-life balance and their options beyond the ivory towers. They need to know how to recognize meningococcemia, but they also need to know how to get a parent to recognize it over the telephone. They need to know when to admit a patient, but also how to bill for that admission. They need to know how to convince a skeptical teenager of a treatment plan, and how to negotiate a partnership contract.

Physicians don’t have to work at a medical school to teach – they can contribute to career fairs, social media, newsletters, take on elective students in their practice…anything is possible. There are literally hundreds of thousands of years’ of experience out there waiting to be tapped…

So I urge my medical colleagues – reflect on this. Remember your title, your role in history and the potential you have for leaving a legacy of medical practice in your wake, in the form of the next generation of Medical Doctors.

As Hippocrates himself said:

“…I will impart a knowledge of this art to my own sons, and to my teacher’s sons, and to disciples bound by an indenture and oath according to the medical laws…”

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I didn’t get the job I wanted…

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I didn’t get the job I wanted.

And it rocks.

When I was three years old, I told my family I wanted to be a doctor. My grandparents gave me one of those plastic doctor’s kits – the kind with the flimsy plastic stethoscope in a little white bag with a red cross on it. I’ve told people I wanted to be doctor for as long as I can remember. Aside from brief flirtations with the idea of a killer music career and dabbling in astrophysics (!) it would seem as though it’s been a straight line for me.

But, as any medical student or resident can tell you, it’s not quite that simple. What is classified as “a doctor” varies tremendously. I used to think it meant the doctor I saw for my regular childhood checkups, but then I discovered the exciting TV ER dramas and saw a different side to things. My first “specialty” decision was to be “a heart doctor” – and by that I meant a cardiac surgeon I suppose. My rationale for that was simply that while neurosurgery was more complicated there wasn’t much you could actually fix doing that. It was just cutting things out after all 😛

Then I went on a medical student career conference….and loved the idea of pathology. Sorting through disease causes, an intimate understanding of pathophysiology and anatomy…and really yucky cases. Yeah, that sounded cool.

And then I hit medical school, and somewhere along the way I fell in love with viruses. Bacteria were ok, I guess, but I had a real problem remembering all the damn antibiotics and what they did. My categorization for the cephalosporins consisted of “Cephalo-kill-a-lot”, “Cephalo-cost-a-lot” and Ceph-du-jour”. It was pretty pathetic. I also realized that while surgery was indeed incredibly technical and cool…it consisted of a lot of standing up or running around…and I liked to sit down. I also had difficulty putting things back together after I had taken them apart, something which I understand is a prerequisite to being a competent surgeon. So…medicine it was for me.

But then what kind? Kids didn’t like me – I would walk down the street and make them cry. Maybe I had some kind of weird expression on my face – I never figured it out. But old people didn’t get better, at least in the hospital. Each admission added another diagnosis to the list, and the slow downward spiral was a constant reminder of my own mortality. A selfish thought perhaps, but a valid one when it comes to job happiness. I was in a bit of a quandary.

And then what about teaching and research? Well, I did like teaching, so that would be nice. I had some practice at that during my PhD years. But I had been told that “Those who can, do – those who can’t, teach.” I wasn’t sure I wanted to get lumped in with that.

And as for research – well, I really like bench research. Don’t ever call it “basic science”. It’s not “basic” – it’s actually quite complicated 😉 I remember several people telling me that with the mix of PhD and MB I could go into clinical trials. I pooh-poohed the idea, since I didn’t want to work for the evil money-grubbing pharmaceutical companies. I wanted pure science.

I gradually found myself gravitating to an outpatient office-based way of life. General Practice or Psychiatry interested me – treating the patient instead of the disease (but wait, didn’t I like pathology…? How did that happen..?) Maybe I just liked to talk a lot. I dunno. In any case, at some point when I was planning on moving to the US I sent an email to a pediatrician here – a contact of my wife’s family. He replied that he couldn’t help me with psychiatry or family medicine (as it is called in the US) but I could come over for an elective.

I rather cunningly selected Pediatric Infectious Disease as my rotation, since I would get to work with him. It turned out well. At the end of it I was offered a research job with him for a year, while I worked on the USMLE exams. His boss, the division chief, asked me if I wanted to do clinical trials work. Torn between my thoughts about Big Pharma and my future job prospects…I said yes.

Fast forward 7 years. What did the medical student who didn’t get on with kids, hated antibiotics, didn’t want to do clinical trials and who loved bench research end up doing?

Here I am, an Attending in Pediatric Infectious Disease. In charge of, of all things, an antibiotic stewardship program. I have taken part in over a dozen clinical trials for pharmaceutical companies, and not done any real bench research since I left the UK. I have created a new curriculum and won awards for teaching. My first week on service as “the real thing” has been at times stressful, busy, fun frustrating, but at every step of the way IT FEELS RIGHT. This is what I feel I am meant to be doing.

The bottom line is that whatever you think you want to be, you never can tell where life will take you. Keep your options open and give things a try. Even a couple of years ago the idea of heading up a stewardship program wasn’t on my radar. Who knows what the next 5 years will bring…

Oh yeah, and kids smile and wave at me in the street now. I still don’t know why.

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Nearly done

I’m awake.

It’s early.

I don’t have to be awake, but I can’t sleep. You see, this is my last day of service.

Not my last day of work – no, I have that tomorrow – but for whatever reason my mind is aglow with whirling transient nodes of thought (Blazing Saddles reference for you) and I can’t get back to sleep. I’ve just caught up with some outstanding dictations (outstanding in that they are late, not that they are in any way good) and so I thought I’d reflect a bit.

I’ve been at Upstate for the past 7 1/2 years. I showed up here as a medical student, post-PhD, not yet done with my medical training and not yet certain about even doing Pediatrics as a career. I had set up a month-long elective in Pediatric Infectious Disease because (A) my one and only US medical contact was a Peds ID faculty member and, er, that was it. I figured I should brown-nose a bit.

No seriously, that was it.

At the end of that month I had somehow got the next 7 years all planned out… This guy hired me to work for him doing research and clinical trials for a year. I took my USMLE exams. I applied for residency (Upstate was the only place I applied to). It was taken for granted that I would transition into the ID Fellowship, which I did, so I have just been part of the furniture here for all that time.

I'm second in from the left, back row...

I have seen the new Children’s Hospital grow from a mythical idea to scaffolding to wonderful newly equipped spacious rooms. I have supervised medical students, watched them grow as Residents and young people, and seen them graduate and start work as Faculty. I have made mistakes, learned a lot, learned that I have a lot still to learn, and I like to think that somewhere along the way I saved a few lives. I’m not sure I’ve actually achieved anything quite so grand – but I’m pretty sure I had a positive impact on an awful lot of kids.

I certainly can’t claim to be the world’s best resident – I have had plenty of peers and colleagues who were better doctors than me: more knowledgeable, more intuitive, harder working, better at getting IV’s started…but I have found that I am good at what I do. I am good with patients and families, I actively practice patient-centered care, I can teach effectively and I can do research. Give me a database and a few hours to code and I can churn out some cool stuff.

It’s a weird feeling to move on – to a job where there are things to get done, where I won’t have the kind of supervisory backup that I’ve enjoyed as a trainee, but where I’ll also have the freedom to practice medicine and work more along my own path. The light at the end of the tunnel has turned out to be an oncoming express train…and I don’t think it truly hit me (pardon the expression) until the past few days. My last 2 weeks of service have been too busy to think about it! Now suddenly, here I am, wrapping up my last dictations and preparing my last lecture. I need to bring boxes to my office to empty it: how weird is that? There are an awful lot of really, really cool people I’m going to miss at Upstate. Nurses, lab techs, pharmacists, Docs – so many people who I’ve worked with over the past few years and got to know. They shaped how I practice medicine. I think that may be the most intimidating thing about having to move – having to re-learn all the ways and intricacies of a new system, a new place. I’ll be flying blind for a bit. I figure it’s worth it.

The thing to remember, and this is a crucial thing for any aspiring doctors to realize, is that I really enjoy what I do. Whatever fluke of fate brought me to Upstate and Peds ID, I can truly say that I don’t think I’d be happier doing something else. Pediatrics wins over any adult care for me, every time. And Infectious Disease…? There’s just something about finding a cause for a disease and killing it. You can’t do that for hypertension, or asthma, or obesity, or diabetes – “You’ve got the bugs, we’ve got the drugs” became my catchphrase.

Confucius said “If you love your job, you’ll never work a day in your life.” He was right.

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