Wednesday, January 31, 2007

A job for the Department of Weights and Measures

You know the Department of Weights and Measures, that agency that goes around checking the accuracy of various scales, meters, weights, etc., all for the public good? That benevolent branch of the government that makes sure that gas stations don't rip you off by dispensing less gasoline than they claim? Well, I have a job for them, and it’s a consultation of some importance, if I do say so myself.

I’m not talking about Iraq, that disaster where our government in its rush to produce oil neglected to install meters on the oil pipes, making it impossible to know how much oil was actually flowing out. No, the Department of Weights and Measures actually requires meters in place before it can perform a consultation. Neither am I talking about medical school, which cost me something like $35,000 annually to sit in a lecture hall for the first two years and then run around hospitals helping out doctors in any way that I could for the next two. That one didn’t add up quite right either, I have to say, but unfortunately I don’t think the Department of Weights and Measures can do anything about it.

No, the consultation that I had in mind deals with the hospital pain scale, that simple yet practical measuring tool used to quantify the intensity of a patient’s pain. The pain scale comes in a variety of formats and colors, from the very straightforward one-to-ten numbered scale to the brightly colored face chart showing cartoon faces in different degrees of distress. (Instead of making the faces themselves, the patients point to the illustration that best demonstrates their degree of agony. Communicating human suffering has never been so easy!) Unfortunately, lately the pain scale has been causing me all kinds of grief, so let me explain the problem, starting with an example.

The other night when I was evaluating a patient with abdominal pain, I asked him to rate the severity of his pain on a scale of one to ten, with ten being the absolute worst pain he could imagine. The man furrowed his brow for a moment and then smiled, rubbed his belly, and looking as content as Drew Carey might look after finishing a bowl of ice cream, calmly reported an eight. Now, if I hadn’t already been acutely aware that my pain scale was having calibration problems, this would have greatly surprised me. "An eight?" I would have asked, bewildered. "You mean that as I’m standing here asking you these questions you are going through terrible, deep-to-the-bone, hand-on-a-hot-stove, weak-in-the-knees, soul-searching, gut-wrenching agony?” Maybe I simply have a particularly fertile imagination, but 80% of the worst possible pain I can imagine is still a heck of a lot of pain.

Instead I casually commented, "all right," and rather than running to find the nearest nurse to deliver a dose of that blessed panacea morphine, I nonchalantly continued onward through the next five pages of my history and physical questionnaire. It was just an eight after all. His experience, rather than that of having all of the hairs on his body savagely ripped out at once, was merely that of having 80% of his body hair ripped out. There’s definitely a difference. Not that I haven’t seen tens who looked more comfortable than this particular patient. Some of my tens, yawning, look more interested in taking their next nap than in pain relief. When that happens, I sometimes feel a need to add some urgency to the situation myself, to make up for their apathy and just to keep the situation from becoming farcical. “Wow!” I’ll exclaim. “Child birth kind of pain! I’m surprised you’re able to handle it so calmly, let me run right now and get something to try and take the edge off!”

The problem I seem to be having with my pain scale is that it is lopsided, falsely weighted towards the higher side, as if Shaquille O'Neal were sitting on the ten trying to seesaw with Peewee Herman sitting on the one. As supporting evidence, I submit the following fact: since I started clinical medicine four years ago, I've never once had a one. I must have used my pain scale thousands of times with thousands of different people, but never ever has somebody reported to me that their pain is simply a one out of ten. Oh, I've had hundreds of tens, scores of twelves, handfuls of hundreds, and even a few thousands. I did have a two once. I was ecstatic, besides myself, standing on the other side of the room. I shook the man's hand. “Sir,” I said "you are a fine specimen of a man. This may sound funny to you, but you are my first two, and although that may not seem remarkable, trust me, it is. You are a rare breed, a throwback to a different age, and a true gentleman if there ever so much as was one.” He apologized for having bothered me with a two, and I loved him even more for it.

Now, some skeptics out there might contend that although I’ve never had a one, I’ve never had an eleven either. Could it not be that my pain scale is working perfectly fine, and that it just so has happened that I’ve cared for a lot of patients who have had a lot of pain? To these naysayers I freely admit that it’s true, I’ve never encountered an eleven. However, eleven is not a number between one and ten and therefore cannot technically be considered a valid response on my scale. Therefore, I still must submit that the score distribution on my pain scale is very suspicious, and that I may indeed have a problem on my hands worthy of the attention of the Department of Weights and Measures.

I’ve come to realize that evaluating pain is a war of rhetoric between physicians and patients, and that it’s a conflict that is only escalating in degree. I'm not sure who started it, but I am keenly aware of being deeply entrenched in the battle. After becoming convinced that my patients were artificially inflating their pain scores in order to impress me with their pain, I decided to take action. I started deflating the numbers for them. I invented the “reality factor”, a carefully worked-out constant that corrects for the increased sensitivity to pain of the modern age. Let’s face it, men aren’t what they used to be, and neither are women. Therefore, in order to correct these systematically inflated pain scores, I began adjusting all scores by a factor of 0.8. A ten became an eight, a six a five. It was a stroke of genius.

Unfortunately, some of my patients are catching on. Sensing that I am deflating their pain scores (although I do believe that the details of the reality factor still remain secure), these patients are readjusting their scores preemptively to account for my “correction”. Where they might previously have reported twelves, these savvy guerillas are now reporting scores of sixteen, eighteen, even twenty. Frankly, I feel at a loss -- outdone and outmaneuvered. Don’t count me out entirely yet, though, because I’m planning a strategic move bolder than anything I’ve tried before, what I’m convinced will become a landmark victory for truth and accuracy in reporting. Just as Nabisco, in response to healthier snack foods encroaching upon its historical territory, launched its blockbuster product the Double Stuffed Oreo, so too am I going to raise my game to the next level. My brainchild? The "double dose of reality factor". The world will never be the same. This factor works its magic by taking the reality factor-corrected pain score and multiplying it by an additional constant of 0.6. When somebody reports a ten, the "reality factor" corrects the score to an eight, but the "double dose of reality factor" then corrects it further to a five (8*0.6= 5). It’s brilliant! Pain will never be treated out of proportion to its actual existence again!

Wait a minute, I'm confused. Little numbers are running around in circles in my head. I’m seeing ant wars, dancing turtles, flying headless chickens. Ok, a patient states his pain is an eighteen out of ten -- quick, how much morphine do I order? Fourteen milligrams IV? Twenty three milligrams PO? Nineteen milligrams SC? Uh . . . uh. . . uh. . . Help! HELP!

Dear Department of Weights and Measures, if you truly exist and are out there, hear my plea! I need a consultation, stat! Please bring your bag of tools, your measure-correcters, your scale-straighteners, in fact, all of the gizmos and gadgets at your disposal, because the problem that I have for you is one of monstrous proportions. I beg you, please come by my hospital once and for all and fix that broken and dysfunctional device that is the hospital pain scale.

Tuesday, January 23, 2007

These DC streets

As DC residents, one of the issues that we all have to come to terms with is how to handle the daily requests for money from street beggars. They are as much a part of DC’s urban landscape as the hotdog stands, the museums, the wide sidewalks, the square buildings, and the ubiquitous identification badges, with one key difference: they don’t stay in the background. DC’s street people are experienced enough to realize that being successful in their business doesn’t involve letting you pass them by unsolicited.

We all probably have different strategies and philosophies when it comes to dealing with them, and my approach has been evolving. When I first moved here a year and a half ago, I made regular contributions to their coffers. I figured that anybody who needed a dollar badly enough to ask me for it probably needed it more than I did, and I never seemed to miss the money after giving it away. The thought that the person might spend it on alcohol or drugs never bothered me that much; after all, they also needed money for food, clothes, and other important things. Gradually, though, I came to feel overwhelmed by all of the requests for money. Walking to and from work, I would pass at least a dozen or so beggars, and at one point I realized that walking had become more expensive than riding the metro. Mind you, I wasn’t giving money to every person along my path, but giving even to a fraction of them was adding up. Taking walks around the city in the evening, one of my favorite things to do, had become not only expensive, but mentally and emotionally exhausting. I was tired of evaluating all of these cases to determine their merit and constantly having to brace myself for withholding aid from people. I wasn’t willing to give up my walks; instead, I stopped the giving. I figured I’d let my DC tax dollars do the work for a while – I knew from working with indigent patients in the hospital that multiple shelters, soup kitchens, and other services are available throughout the city for those in need.

I let myself become hardened. One of the things that I overcame was the fundamental need to be polite. I realized that the best beggars were preying on my politeness, manipulating it by dragging me through their stories, shaking my hand, or buddying up to me in ways that made it extremely difficult for me later to refuse them money. I came to see, though, that as strangers doing these things to me, they were the ones who were behaving badly, who were breaching etiquette. I didn’t need to be polite, or to extend them the courtesy of hearing them out just so that they could take advantage of it. I still acknowledged people, but I no longer listened to their requests; “sorry,” became my one-word response.

The unfortunate consequence of the hardened me was that, like most Washingtonians, I became difficult to approach in the street. Unless I could see that you were clearly either lost or a tourist, I was not going to stop for you. A few weeks ago when I was out for a walk with my brother, we passed a group of three young teenage girls on a corner block who appeared to be just hanging out. As we walked by, though, one of them called out to me, “Sir, would you be willing to contribute to our school band fundraiser?”
“Sorry,” was my automatic response. I only took one more step before I turned back around.
“Did you say school band?” I asked, delighted.
The girls nodded.
“Hey, I was the captain of my high school band. What instruments do you guys play?”
“The clarinet,” one offered.
“Me too.”
“The flute,” said the third, shyly.
“Do you guys march?”
“Yeah,” said the first, with the other two nodding in agreement.
“Well, I played the trombone. I’m from Alaska and it was too cold for us to have a marching band, but we played at the basketball games.”
They smiled and I signed my name on their list of donors.

The nice thing about refusing all routine street requests for money is that it frees you to give when you really want to. Of course, these girls were band members, not street beggars, but to me the point was that I was giving freely, not out of awkwardness, guilt, or undue pressure. The upside of the new me, it turned out, was that I could be a virtual ATM when I felt like it.

Sometime thereafter, I was walking around downtown on a day off, and a pleasant-mannered, pleasant-appearing, middle-aged man approached me, asking for a second of my time. He hated to bother me, he said, but he had just rolled into town from North Carolina, and he was going to have surgery here in a few days, but the hospital (which happened to be one of the hospitals at which I rotate) hadn’t helped him to arrange accommodations. It was two days before he would be able to check into the hospital, and he had no money and no place to stay. He wondered if I wouldn’t be able to help him out.

I didn’t share with him that I was a doctor at the hospital where he would be having his surgery in a few days and that for all I knew I would be his doctor, or that he had somehow connected with a boyhood fantasy of mine that there is something romantic to the notion of hopping on a bus to Washington without a penny to your name or any definite plans. The money, however, never flowed so easily.
“Sure, I’d be happy to help you out. You’d have thought the hospital would have done more about the arrangements.”

I’m not sure that I’ve arrived at any ultimate destination in terms of handling street solicitations, but I have come now to a comfortable place. Being able to give on my own terms signals not only that I've become more secure with myself, but that I’ve settled upon a harmonious way of living with the other people who populate these DC streets. Necessarily so, it’s a way that respects both their humanity and my own integrity.

Wednesday, January 17, 2007

The art of apology

Recently I admitted a patient whom I told I was going to give a blood transfusion, but didn’t. You see, when his repeat blood count came back, it showed that the transfusion probably wasn’t necessary. I canceled the order pleased that I was sparing him an unnecessary transfusion, but unfortunately, I never told him that. He lay in bed all night wondering where the heck his blood was, just waiting for the transfusion to start. When I popped into his room for morning rounds, he understandably was irritated. I brightly announced that he wouldn’t need a transfusion after all, to which he responded sourly, “it would have been nice if somebody would have told me that last night.”
“Oh, sorry, didn’t the nurse tell you?” I asked uneasily.
“No, nobody told me.”

I left the room not only feeling guilty about having been remiss in updating him the night before, but professionally embarrassed because I was now going to have to pass off a grumpy patient to the day team. I also felt ashamed at having tried to blame his nurse, and enough so that before leaving the hospital I went back into his room.

“Hey, I just wanted to say I’m sorry for leaving you in the dark last night. I should have been the one to tell you that the transfusion was off, not the nurse. I'm the one at fault.”
His mood shifted completely.
“That’s all right,” he said smiling warmly. “Say, it’s shaping up to be a mighty fine day, do you think I’ll be able to go home by this afternoon?”
I grinned. “We’ll see what we can do.”
I was forgiven, and I felt so much better.

Sometimes I feel like I’m the only one who has noticed that it can feel really good to apologize. Not that the apologizing itself is so great – you do after all have to admit that you were wrong – but the potential for forgiveness can make it very appealing. Think about it – you injured somebody, but through apologizing you have a chance to restore relations and make amends, even to wipe the slate clean. That’s powerful. Yet, we live in a society that is loathe to apologize. Our celebrities and leaders rarely apologize, and when they do it is done so cautiously that it hardly seems like an apology at all. Any admission of wrongdoing is removed, and the blame is often placed on the offended party for misinterpreting the well-intentioned words of the apologizer.

Consider the Pope. Back in October, in a move that probably wasn’t his wisest, the Pope quoted 14th century Christian Byzantine emperor Manuel II on Islam in a speech at the University of Regensburg in Germany:

Show me just what Mohammed brought that was new, and there you will find things only evil and inhuman, such as his command to spread by the sword the faith he preached.

Afterwards, he issued the following ”apology”:

At this time, I wish also to add that I am deeply sorry for the reactions in some countries to a few passages of my address at the University of Regensburg, which were considered offensive to the sensibility of Muslims. These in fact were a quotation from a medieval text, which do not in any way express my personal thought.

I’m sorry for your over-reaction? If that’s not heartfelt I don’t know what is. For some reason people seem to think that if they can include the word “sorry” somewhere in a statement, it then becomes an apology. Pope Benedict’s apology only deepened the initial insult by affirming that he stood by his original statement, and by insinuating that those who were offended were actually the ones in the wrong.

To me, explaining what exactly you are sorry for is one of the key elements to a good apology. An ex-girlfriend of mine used to refuse to do that. She said that if I didn’t know what she was apologizing for, I probably didn’t deserve the apology in the first place. To her, an apology was a three-word phrase, spit out as if it was some despicable thing: “Fine, I’m sorry!” Unfortunately, besides obscuring the apology’s meaning and making me question its sincerity, this also left me in the position of doubting whether she knew what she was apologizing for herself. (e.g. that she wrongly accused me of forgetting to take the car in for repairs, that she refused to talk to me for two hours afterwards, or that she called me an incompetent idiot during the ensuing fight)

Apologizing can be difficult, though, and sometimes we’re not sure exactly how we hurt somebody. If, as someone who was wronged you are able to explain your feelings and don’t insist completely on the other person figuring them out on his or her own, you are going to receive much better apologies. Asking for (not demanding) an apology can be a great way to resolve a conflict. A good discussion can often also lead to a double apology – after you apologize the other person both accepts and apologizes back, usually for over-reacting or handling the misunderstanding ungraciously. With a double apology, you really know you are forgiven. I think that might have been what Pope Benedict was going for when he got the parts mixed up: he was supposed to apologize for what he said, and the Muslim leaders were supposed to apologize for the over-reaction, not the other way around.

As physicians we’re really bad at apologizing, for multiple reasons. We’d like to blame it mostly on the lawyers, but the truth is that most of us (66% in a large study published by the Archives of Internal Medicine) believe that apologizing to patients actually reduces our medical liability. Even if the legal climate doesn’t prevent us from apologizing, though, I think it does negatively impact the language that we use. When pronouncing people dead, for example, we commonly tell family members, “I’m sorry for your loss.” To me this just sounds cold and detached, and I think the reason we say it that way is because we want to be clear that we aren’t accepting any liability for the death. Expressing sorrow for death, though, is a benevolent apology that doesn’t naturally imply accountability. I prefer the more simple, “I’m so sorry,” which I think shows family members that I’m on their side.

I suspect that what we’re really afraid of in apologizing and admitting medical mistakes to patients is losing their confidence. Without the trust of our patients, we are worthless as doctors, and that is a frightening proposition.

The art of apology is tricky and filled with potential pitfalls and misunderstandings, but I wish that our leaders would be more ready to put themselves on the line with higher quality apologies. A person willing to apologize is a person whom I’m willing to trust, but someone who withholds apologies is either weak or mean-spirited. The difficulty and fear involved are not reasons to back away from apologies, but are what make them refreshing and meaningful in the first place. Without them, forgiveness can simply not be granted. And I would suggest that when you’ve hurt somebody and feel bad about it, there’s nothing better than to be forgiven.

Monday, January 08, 2007

Top ten ways to get back at your intern

I’m not condoning an all out war with the medical intern; certainly, the most fruitful doctor-patient relationships are those built upon mutual trust and respect. Nevertheless, there are times at which it may be appropriate to behave in ways towards him or her that otherwise would be considered counterproductive, if not totally suspect. For example, let’s say you don’t like your intern. Maybe the guy’s an arrogant prick with about as much common sense as a rock toad. Maybe he went to Ohio State and you are from Michigan. Maybe he forgot (or so he said) to order your sleeping pill. Whatever the reason, an intern like that needs to be dealt with swiftly and severely, and I here offer a list of tried and true insider methods that are guaranteed to get his goat.

Before proceeding to the list, I’m going to warn you that some of the things I’m proposing may seem somewhat harsh and unnecessary. That’s nonsense. Part of the reason you came to a teaching hospital in the first place (besides the allure of the pretty, young female medical students and residents) was to allow your illness to help train the next generation of physicians. (And yes, it is reasonable to hold against your intern that he’s not a beautiful young girl.) What kind of training would it be without any challenges to overcome? Do you really want to be responsible for your physician-in-training failing later in his career because he was never tested during residency?

There’s another consideration as well, and that is the extreme boredom of staying in a hospital room for many days, simply staring at the ceiling or the TV. Nobody is going to fault you for infusing a little bit of melodrama into your relationship with the medical team, just for the heck of it. Besides, keeping yourself occupied will prevent the boredom from driving you to more dangerous kinds of mischief.

10. Think of your intern not as your doctor, but as your biographer: she is there to learn and record your life story. Do not leave out any of the details and do not let her cut you off. You wouldn’t want to compromise her work, would you? With practice, you can make a pre-round visit last up to an hour.

9. When your intern arrives with his attending on morning rounds, ask him to explain how your chemotherapy medications work. Seek out and exploit any weaknesses in the explanation.

8. When your intern first comes to introduce herself, suggest that the patient she is looking for was just moved upstairs. Start your timer to see how long it takes her to come back. Besides letting her know from the start who’s in charge, this will let you measure her competence. If she returns in less than a minute, you’ve got a star on your hands. If it’s within ten minutes that isn’t bad, but if it takes more than fifteen minutes, brace yourself because you’re dealing with a trainwreck who’s going to require a lot of extra training.

7. Writhe in pain on attending rounds, denying that you said you felt great to the intern thirty minutes ago. Alternatively, writhe in pain for the intern and look great for the attending. This will undermine the intern’s credibility in case she later tries to call you out on any of your pranks.

6. During attending rounds, claim that some rascal stole your jewelry. Compliment the intern on her bracelet and mention that it looks an awful lot like your old one.

5. When your intern comes into your room on pre-rounds, just before his exam declare an urgent need to use the restroom. Bring a good book for the toilet seat. Something like War and Peace.

4. On attending rounds, ask the intern if you were sleeping when she came to pre-round, because you don’t remember her visiting you earlier that day. If she recovers from that one, ask her if she really is sure that you’re dying.

3. Declare a game of hide-and-seek with your intern (don’t tell him, he’ll figure it out), with him being “it”. There are all kinds of interesting places to hide in a hospital.

2. After polishing off your breakfast and telling your intern that your appetite has been great, call down to the cafeteria and order a second tray, to be left untouched by your bedside waiting for attending rounds.

1.At the time of discharge, forget where you put your house keys. Have no idea how you are going to get back into your home. Consider it a final test of your intern: if he is able to see the discharge through and can arrange a way for you to be brought inside your home, then you know his training has been successful and that he’s ready to be let loose on the world.

Employing the techniques described above will undoubtedly enhance the entertainment value of your hospital stay. As a final comment, I'd like to point out that the discharge is one the most dangerous time during a hospitalization. Medications can be missed, follow-up plans neglected, and instructions glossed over, leading to re-hospitalization often under scary conditions. You don't want that, and neither does your intern. If you use my tactics of getting back (or simply getting at) your intern, you can be assured that your discharge will never be handled with so much careful attention to detail--the poor kid will do everything in his power to make sure that he never has to see your face again.


Intern: first year medical resident
Attending: supervising physician
Pre-rounds: when your intern checks in on you early in the morning before presenting your case to the attending
Attending rounds: when the intern returns to your room with the attending, so that he or she may also see and assess you

Monday, January 01, 2007

Cycles and time

A few months ago my brother and I were sitting around one evening watching the US Open tennis final, and he wondered, what if scoring in tennis were simplified to being the first man to 100 points, period. No games, no sets, no tie-breakers, none of that confusion, just points, and when one player has reached 100, the match is over. It would make more sense and be easier to follow, he pointed out. There would never be any doubt as to who was ahead at any given moment. After thinking it over, though, we concluded that nothing would kill the sport of tennis more readily. The deuces, the mini-games, the key points, the breaks of service, indeed, all of the elements that make tennis fun to watch depend upon the traditional game-set structure. Without them, and without the moments of tension and release that they produce, tennis would be a very dull sport.

We are a cyclical people living in a world of cycles. Although we did not invent the concept of years, seasons, and days – cycles that are mandated by the stars – we have grown dependent upon them. We need them to help us process the passing of time, and to help us order our lives. Imagine if we didn’t have years, if we instead measured time in terms of days, for example. Some days that would be important to remember: 4745, the day at which you can finally get in to a PG-13 movie; 6574, the day at which a girl becomes legal; 7665, the day at which drinking alcohol is no longer illegal; 12775, the day when a woman’s biological clock runs out; 17520, the average age for a mid-life crisis; 23725, the day at which you can begin collecting social security (at the cost of finally having to admit you’re an old man). Counting time in days might have its charm, but what a headache it would be to remember all of those numbers! Give me a cycle, not a line.

Thus, when people tell me there’s nothing special about New Year’s, that it’s just another day, that a New Year’s resolution is no more timely than any other resolution and that if truly worthwhile it should be carried out at its moment of conception, I say wait a minute, that’s simply not true. New Year’s marks the end of one year and the beginning of the next – it represents the ticking of the most significant division of time that we have. If we believe at all in the possibility of change, of new beginnings, of new chapters and new leases, of building new accomplishments upon past ones, then a new year is the most natural time to renew those efforts.

I don’t wish to suggest that the year is the only meaningful unit with which to measure time; the seasons are lovely as well, and they have frequently been an inspiration for music composers, such as for Vivaldi and Piazzolla in their seasons cycles. Medically, the seasons are the most interesting. When checking the mental status of patients, orientation to time is one of the basic measures of cognitive function that we assess. In the hospital, because there are few clocks, no calendars, no clear days or nights, and vital sign and medications schedules pay no attention to daytime-nighttime cycles, disorientation to time is a frequent problem. While we ask about years and months and dates, I find orientation to season to be most telling. If the patient knows the season, I can be reassured that he'll probably be all right. His perception of reality might be somewhat altered, but his fundamental hold on when he's living remains intact.

This is New Year’s Eve, though, and the discussion at hand is one of years, not of seasons. Tomorrow will be the first day of a new voyage of the earth around the sun, and I’m delighted to be here for it. I’d love to let it infuse my own life with fresh energy. To a tennis player, a new set means new life, another chance to fight for a come-from-behind victory. I don’t see why a new year for me should be any different. I have a feeling it's going to be a good one.