Thursday, August 31, 2006

The tin psychiatrist

He was a charming man, but an operator too smooth, greased from head to toe in the lubricant that runs the machine. On Tuesdays he played golf with local top executives at the most exclusive country clubs. Two other days a week, he dined with pharmaceutical representatives (only the most attractive female ones) at fancy restaurants. Psychiatrist by training and practice, he was also my mentor for some extra-curricular shadowing that I had arranged during my second year of medical school. Strictly speaking, he was more of a pharmacotherapist – he avoided psychotherapy as much as possible – his clinic patients had five minute appointments and he would squeeze in thirty patients per morning as this maximized efficiency and profits. He had the business of medicine all figured out.

Besides his clinic duties, our psychiatrist spent a fair amount of time in a downtown rehab center, and it was when I followed him there one afternoon that his behavior made a lasting impression upon me. He took me into his musty, oak furniture office, sat me down, and began to tell me briefly about two patients we were to interview that afternoon. He pulled out their files, shuffled some papers around, and then to my surprise picked up the tape recorder on his desk, flipped it on, and began dictating the first patient encounter. He sped through it, in sixty seconds documenting the patient’s appearance, mood, concerns, his assessment and plan, and everything else that belongs in a note for a thirty minute psychiatric patient visit.

This confused me--I was pretty sure we hadn’t seen the patients yet, unless he had already seen them during lunch before I arrived, yet he had talked to me about the patients as if we were going to see them together. Before I had a chance to ask, however, he was off dictating the second patient encounter. This one took all of seventy seconds, and by the end of it I had mustered up about all the courage that I could find.
“You dictate your notes before you see your patients?” I intoned as innocently as possible.
Looking at me for a brief second, he shrugged, “Yeah, I already know what they are going to tell me, it’s the same every time, and doing it this way helps me stay more organized.”
In afterthought, he added, “If anything turns out differently, I go back and change it.”
We proceeded to see the two patients, and as he had predicted, there were no major surprises.

Fast forward four years, and the other day I found myself writing a progress note for a patient using a computer template. She was a patient that I had taken care of all month who was no longer acutely ill and whom I knew very well, and I printed off the progress note in advance of seeing her, leaving blanks for the subjective findings. After seeing her, as I filled in my note, my eyes settled upon the physical exam section, which I had typed in earlier that morning, but which I could only now verify as being accurate. Remembering our dear psychiatrist, I shuddered and hastily scribbled in some additional physical findings.

Thank you, sir, for you were my teacher too.

Wednesday, August 30, 2006

Medicine for our mothers

We hear it about once a week on wards, at times when particularly troubling or trying decisions arise regarding patient care. Usually, it’s the attending who poses the question, but it’s always spoken from a more senior to less senior team member, as it carries a subtle implication that the currently proposed plan may not be quite good enough: “If it were your mother, what would you do?” The effect that this question has upon the team is both striking and predictable. (It does rely on the assumption that the team members love their mothers, but would they really have become doctors if they didn’t?) Several moments of chin rubbing, head scratching and soul searching ensue, after which it is generally agreed to raise the level of care or renew efforts with yet another attempt at diagnosis or therapy. Occasionally the question instead spurs a move towards patient comfort or palliation. All involved are reassured that the patient is getting the best possible care because it is what they would have done for their own mothers.

The mother hypothetical is a ritual of medicine that I have participated in countless times, although I’ve never raised the question myself. Somewhere between my 4th year of medical school and internship its great irony struck me. As physicians we are forbidden from practicing medicine on our mothers for the very reason that when it comes to them, we are completely incapable of reason, rationality, or measured decision making. Yet with our most difficult decisions, at the times when we most should be relying upon reason to guide us, we instead emotively plea for guidance to the specters of our beloved mothers. Oddly enough, it usually helps. Still, I have to wonder, are we asking the right question? Does mother know best? Perhaps our decision making would be better if we instead pondered about Uncle Albert. Or, an even more novel concept, what if we just asked what was best for that patient?

Tuesday, August 29, 2006

Lighting the lantern

A lack of conversation, that’s the problem I’m trying to address with this blog. As medical residents, our lives are filled with incredibly rich daily experiences—we witness miracles and tragedies, encounter the extremes of human behavior, face and sometimes overcome daunting challenges. Yet, we don’t talk about it. We don’t talk about our experiences and we don’t talk about how those experiences affect our lives and shape us as ordinary people. You’d think we would, but we don’t. In house, well, we’re too busy—there are patients waiting to be seen and duty hour rules to follow. Socially, well, nobody wants to be the party spoiler bringing up medical shoptalk. At home, well, I think for various reasons we’re just reluctant to bring that conversation into our homes.

Having now finished intern year and moved on to the distinguished rank of PGY2, I’ve consumed so much residency experience that it’s backed up my throat and flowing out my ears. Indigestion is my ailment; Foggy Bottom Lantern my proposed therapy. The conversation I want to hold here is one about the experiences of residency – the trivial, the substantive, and the profound. Gather ‘round the lantern, friends, lets trade stories and help our alimentary tracts digest what we’ve seen and discovered.