Happy Holidays, You Might Have Cancer

It was the day before Thanksgiving. The menu was planned, the shopping done. I planned on baking pies and chopping vegetables once I got home. Only a few patients to see that day, one a new patient. Usually my NP doesn’t see new patients, as initial evaluation is left to the physician.

She was flustered about seeing this patient she’s never met. Rushing into clinic to see the NP usually means something is urgent. This particular patient was highly symptomatic following a procedure by another provider. Unable to provide an explanation for her sudden shortness of breath, that provider referred her to our clinic.

The sudden onset and change in her symptoms frightened the patient and her husband. A young woman who enjoyed exercising was panting after walking less than 10 feet. Looking over the results from labwork, procedures, and imaging didn’t reveal a clear picture. She looked at us, pleading for answers with big, round eyes. She held her hand tight as her husband helped answer questions so she could catch her breath.

Imaging showed an abnormality, not explained by the most common diagnosis. The suspicion arose for cancer, though more testing would be needed. By the way her face fell, she had obviously not considered such a disastrous possibility. Her procedure was supposed to be simple and easy. From a cardiac perspective, it had been successful. Now she and her healthcare providers were forced to contemplate more malignant causes.

Despite working in a medical clinic, I’m not accustomed to seeing my patients die. We primarily see patients with atrial fibrillation, a treatable and manageable disease not likely to be the sole cause of death. The interventional team has to worry about death from heart attacks, while the heart failure team deals with high risk transplant candidates or LVAD patients. Cancer is usually handled by outside physicians specializing in other bodily systems and/or oncologists.

Right before the holidays, even the most remote possibility of cancer seemed devastating. It was difficult to hold myself together for the patient’s sake.

One of the research physicians suggested that I begin hospice volunteering. Despite all my research and reading book after book about death, I have little experience with confronting the ultimate partner to medicine. Perhaps it’s best I heed his advice.

Shadowing: MS Clinic

I’ve probably only spent 6-9 hours scribing for the neurology clinic. The provider I worked with is older than the average physician. His expertise lies in the treatment of multiple sclerosis (MS). MS is an auto-immune disease in which the body attacks the myelinating sheaths over the nerves of the nervous system. It can be diagnosed with lesions apparent on brain imaging, but symptoms vary. Usually there is some component of chronic pain, disability due to lack of coordination or difficulty with motor movement, and fatigue.

MS is often confused with fibromyalgia (which is a clinical diagnosis not based on brain imaging). Patients with chronic pain are often over-diagnosed with MS. Though the reasoning may be unclear, it may be a last-ditch effort to diagnose a patient with something, anything that could lead to a treatment plan. Extensive work by Dr. Andrew Solomon has explored how often MS is incorrectly attributed to patients and how to improve diagnosis (as well as how to address the misdiagnosis with patients).

Chronic pain patients get a bad reputation. Some of the negative labels attributed to them are “crazy,” “attention-seeking,” or even “drug-seeking.” I have an aversion to treating chronic pain, which I suspect many pre-meds may have as well. Chronic pain is difficult to attribute to a diagnosis, difficult to treat, and nearly impossible to cure. I’m sure this aversion will resolve with more extensive shadowing and understanding of the physical factors at play.

The provider I worked with is one of the greatest people I’ve ever met, especially as a physician. There are very few people who can make such a strong, empathetic connection with patients. Clinic with him is not like a doctor’s visit, but an engaging conversation in which he and the patient discuss health and treatment options. He is first and foremost a teacher, to patients and staff.

He does not flinch in the face of complicated medical histories, patient pain and emotional struggles, or patient non-compliance. He and his patient come to a truly mutual decision regarding their health and treatment.  He does not shame patients for refusing a certain medication or procedure. The patient only has to explain their reasoning. Whatever it is, he will accept it, as long as they are willing to explain their refusal. The patient feels like they are the one deciding, not the doctor.

I wish I could properly convey the experience of his clinic. He openly admitted to treating me like a resident. In exchange for scribing, he felt he should offer me an opportunity for education. He asked questions and encouraged me to ask questions. All my fear about the lack of neurology knowledge went away. I left more confident and energized. My only disappointment is that I haven’t been able to return for more shadowing.

Have you shadowed in neurology clinic? How was your experience?

Documenting Angry Patients

I’m not really sure what happened this week, but I had two patients whose sole purpose in coming to clinic, was to yell at us. The first patient “fired” us. Patients can fire providers, meaning that they no longer want to receive treatment by that provider. Providers can also fire patients, usually if a patient is non-compliant with treatment or has poor behavior resulting in their expulsion from clinic (violence, harassment, etc.).

Regardless of the reason for firing, the visit must be documented, especially if the patient is refusing further care. This is also true with patients who are suing providers or have additional complaints. Medical records and documents are all accessible by patients and other providers. This means that abrasive, offensive, irritating, or angry conversations must be documented with care.

1) Know When to Quote

Directly quoting patients is a common practice when using the patient’s own words to describe symptoms. When patients describe their palpitations as “fluttering” “sputtering” or in other layman’s terms, I use quotations. When I patient is angry or frustrated, it may be best to avoid quoting. Documenting threats is a must. Expletives and curse words might be better to document as a reference; for example, “patient became verbally abusive, shouting expletives,” as opposed to, “patient said, “**** you you stupid *****!”. Quoting angry phrases may best be re-phrased in more neutral language. My patient said, “You will never touch me again,” but I documented “Patient refused further care.”

2) Document the Reasoning

It is not appropriate to simply document that a patient was angry.  Why was the patient angry? Is it a reasonable complaint? My providers like to be aware of smaller issues to prevent them from occurring in the future. If it is an unreasonable complaint, the provider may review the note if contacted by the same patient.

3) Physical Violence

Physical violence may be more difficult to document. You should never compromise your own safety, just to document what is happening. Fortunately, I’ve never had to worry about this, but I advise documenting as soon as possible (once you are safe, of course). Your memory is more accurate immediately following the incident. Use a voice recording if needed.

4) Use Neutral Phrasing

Medical terminology has several phrases designed to avoid offense, not only for describing physical aspects of a patient but also their emotional state. “Non-compliant” is better than saying “stubborn” or “rude.” Use neutral, accepted language to describe patients whenever possible. You’ll avoid aggravating patients further.

5) Take a Breath

The most important factor is the physician’s frustration. It may be wise to document, then take a break. Step away from the situation, calm down, then return to the note. Read back through your note. Is the note insulting to the patient? Are you heavily biased? Avoid belittling or insulting the patient in their own record. Try to address the cause for misunderstanding in your note while avoiding placing any blame. Sometimes you can explain something 20 times, but the other person won’t understand. It is common sense not to imply a patient’s lack of intelligence, though if you’re caught up in a moment of anger it may be implied.

Do you have any tips on how to handle angry patients?

Reading List: In Shock

Image result for in shock rana awdish

Following on the trend of my last reading list book, In Shock is written by a physician who finds herself in the position of a patient. Unfortunately for Dr. Awdish, she is a critical patient who actually has an out-of-body experience as she codes during emergency surgery.

Following her surgery, the book covers her excruciating recovery from an unknown disease wreaking havoc on her body. This unknown disease cost her her unborn child. While her doctors and nurses struggled for answers, they took out their confusion and frustrations on her. Dr. Awdish became intimately aware of the manifestations of the wall many physicians put up to “be better doctors.”

My favorite habit that she points out is the power of words. Physicians are taught to empathize, but at the same time, cannot take a patient’s pain as their own. Emotionally compromised doctors are not good doctors. Unfortunately, this leads to bad habits. We make macabre jokes and say insensitive or flippant comments that ultimately harm our patients.

One of the phrases she pointed out as harmful was “You kept trying to die on us.” It seems harmless. The physician tries to seem lighthearted about a serious matter. Unfortunately, Dr. Awdish took these words to heart. She felt physicians blamed her for being sick and coding. I know I have said this phrase, maybe not to patients, but definitely when discussing patients with my providers.

The common theme throughout her book is the way that doctors speak to their patients. Now she has made a career of teaching healthcare professionals to watch their words, to think before they speak. I, for one, would love to attend one of her sessions.

Patients trust doctors they can connect with. It’s important to acknowledge their feelings and put them at ease, while acknowledging a patient’s goals and desires. This must be balanced with medical necessity and treatment. It’s difficult, but we’re not becoming doctors because it’s easy.

Have you said any of the phrases that Dr. Awdish condemns? Have you experienced burn-out that manifests itself in blaming patients or venting to them? Let me know how you feel about this book. Is Dr. Awdish right? What changes do you need to make in speaking to patients?

Overcoming Obesity Bias in Healthcare

A woman’s obituary has recently gone viral. After suffering from inoperable cancer,  a Canadian woman named Ellen Bennett passed away. In her obituary, she criticized healthcare professionals for discriminating against her due to her obesity. According to the news outlets, it took many years to receive her cancer diagnosis. She had felt unwell for several years, but apparently was told to lose weight. There has been a wave of sympathy from other self-proclaimed “fat” women who share stories of how diseases and ailments went untreated because healthcare providers encouraged weight loss instead of other treatments.

I can imagine a discussion Mrs. Bennett must have had with her primary care doctor. Perhaps she complained of general fatigue and malaise. If she wasn’t puking, bleeding, or passing out, it wouldn’t be considered an emergency. Unexplained weight loss is usually the biggest red flag for cancer (in my experience). Providers may have assumed depression or fatigue related to her weight. “Lose weight you’ll feel better,” seems to be a pretty common response.

Obesity has been linked to increased risk of several diseases including heart disease (CAD), diabetes, sleep apnea, and high blood pressure. Many have argued that obesity does not indicate health. At age 18, I was nearly 200 lbs. with a BMI of 27 (considered overweight, though I have my issues with the BMI measurement). I had no significant health problems. My heart worked well, and my BP was normal. For all intents and purposes, I was a healthy adult. Though obesity may not indicate general health of a person, studies have shown that even having extra weight can put you at risk regardless of lifestyle. Being obese can also put you at risk during procedures and surgeries. My hospital will often refuse elective surgeries for patients with a BMI over 45 (with the exception of bariatric surgeries).

There’s a dangerous stigma associated with obesity. Many people feel that obesity is the result of “laziness” or “not caring enough” about their health. For some people, this may be the case. For many others, there are multiple unseen issues at work. I once met one woman who had a BMI of 56. A tragic miscarriage had resulted in depression and finding comfort in food (in addition to the weight gained during the pregnancy). Psychological problems, stress, genetics, disease processes, income, and many other factors affect weight.

Our responsibility as physicians is to provide the best care. We cannot approach patients assuming that they do not want to get better. It is irresponsible to place the entirety of a problem on a patient’s weight. When I worked with orthopedics, weight was often a discussion of topic. Surgeons performing knee replacements mentioned weight to alleviate strain on the joint, but also provided medications and injections prior to surgery. Weight was addressed, but not a reason to discriminate or withhold most treatment options. A spine provider encouraged weight loss for a healthier overall lifestyle, not necessarily to alleviate back pain. In his words, “skinny and fat people both have back pain.” Their weight wasn’t the cause, so it likely wouldn’t do much to help alleviate the problem.

Since I used to be overweight, I remember being sensitive about my weight. The training I’ve received at my clinic regarding obesity has been focused on sensitivity. No one wants to be wheeled in the “big” chair, so we’re supposed to refer to it as “bariatric” when necessary. Though we’ve improved hospital and clinic facilities to be more size-inclusive, sensitivity training doesn’t address the stigma associated with obesity. We need to look at weight management as part of the treatment plan, not the only treatment plan.

Docs vs Docs: No One Wins

I’ve had the privilege of working with some world-renowned, extremely talented doctors and surgeons. Patients often come to these providers when they’ve failed treatments, or if they’ve received recommendations and are unsure which treatment may be best for them. Unfortunately, the providers often find their patients’ previous treatment lacking. They ridicule the decisions of other doctors (sometimes even in front of the patient).

Why do doctors attack each other? Their goal is ultimately the same – to treat and/or cure their patients. If two doctors see the same patient for the same problem, there are bound to be differences in approached. Some physicians may prefer certain times of imaging over others. Some physicians may advocate for naturopathic or less invasive treatments to start, whereas some physicians may be more aggressive.

In my experience, primary care physicians (PCPs) receive the brunt of physician-to-physician criticism. The PCP is the jack of all trades, master of none. They are the first-line for their patients. They have a broad understanding of most problems, start with certain treatments, then refer to specialists. Specialists often roll their eyes when patients come in with unnecessary imaging or testing ordered by a PCP. But how is a PCP supposed to know that a spine surgeon prefers MRIs to CTs?

This criticism is not only limited to PCPs. My mentor has a habit of criticizing specialists in the same field of being overly aggressive or performing unnecessary procedures in order to receive additional compensation (which should be considered fraud). As a result, I’m suspicious of many of his colleagues. I question the treatments and decisions made by other specialists.  I may disagree with their decisions, but I wasn’t there to understand why the physician made that decision. In addition, I’m not a physician. I can’t understand their decisions because I am not a trained physician. I’m afraid that this suspicion could affect my ability and willingness to learn from other doctors.

I believe this animosity arises in part from the competition started in medical school. Pre-meds compete for the best grades, the best scores, and the best schools. When we get into medical school, we battle for the best rankings, the best opportunities. Then we compete to match. In residency we strive to out do each other to get better fellowships, better pay, better attending positions. Those attending physicians compete for patients. Throughout the entire journey, there is a strong focus on competition over collaboration.

This approach has been evolving over time as medical schools recognize the cut-throat environment they create. The older generations of physicians, however, do not have the benefit of this approach. What’s more is they teach their residents and fellows to treat their fellow doctors with suspicion.

It is important to address incompetency or intentionally endangering patients. If the decision of a physician intentionally harms a patient, it needs to be addressed through the appropriate channels. My primary concern is not this, but doctors mocking their colleagues because it is not how they would prefer to treat their patient.

What these doctors fail to recognize is that treatments are an agreement between patient and provider. A doctor analyzed a patient’s position, offered options to the patient, and the patient made a joint decision with their doctor. With this arrogance, we create distrust in the relationships with patients. We also erode the trust that another doctor has established with a patient. In the end, both doctors lose. Neither doctor communicates with the other, the patient becomes wary, and treatment may get delayed while the patient considers other options or another opinion.

How do we address this issue? It’s not as easy as accepting differences in treatment approaches. It is understandable to be frustrated by lack of proper testing or treatment. Doctors and patients may feel like they are starting over, which can frustrate the patient as well. I have a few ideas about how to treat this issue with patients.

1) Don’t scoff or mock a doctor in front of the patient.

Referring to someone’s doctor as an “idiot” or “untrained” is rude in general. It also makes you seem arrogant. There’s no need to take out your frustration in front of the patient – it’s unprofessional.

2) Remember your source.

The information provided to you is subjective. Patients can get confused. Records may indicate the exact opposite of what the patient is telling you. What you may mistake for the provider’s problem may just be a misunderstanding.

3) Try to look on the bright side.

Has the patient had testing that you needed? Is there extra imaging that rules out a diagnosis? It’s unfortunate that the patient underwent so much testing, but it saves you time and establishes a greater picture of your patient’s health.

4) Communicate with the provider, if needed.

You’re seeing a patient for an issue. They tell you another provider has ordered a battery of tests. You disagree with the need for some (if not all) of these tests. You tell the patient you don’t find them necessary. Now the patient is confused. They trust the doctor that ordered them, but they also trust your judgment. Speak with the provider, agree on a plan of action, then convey that plan to the patient.

5) Explain your treatment plan to the patient.

The patient has seen a physician with a different plan of treatment. Without belittling the patient or their provider, explain why you’re taking a different approach. The patient needs to understand what’s happening and why. They may be happy to avoid expensive or invasive testing.

Have you heard providers disparage other providers? Do you engage in the negativity? Are my suggestions naive? Comment with your thoughts!

Paging Dr. Google

We’ve all seen it. Patients feel ill and the first place they turn is WebMD. They get their diagnosis from Dr. Google, do their research, and come in prepared to discuss their options based on the print outs from online forums and other websites.

The thing is, we’ve also done it. It doesn’t matter if I’m pre-med, I have used WebMD to soothe my worries about certain symptoms. I get an idea of what I’m dealing with and whether I feel I need to see a professional to be treated. I have the advantage of being able to distinguish between certain diagnoses because of my medical knowledge and experience. The layman does not.

Doctors, nurses, and other healthcare professionals have a tendency to mock patients for this. I would be lying if I said I hadn’t participated in teasing patients about Dr. Google. Unfortunately, by doing this we alienate our patients. Fear is a major factor in illness. Patients don’t (usually) go to medical school. They become ill and afraid. They hear scary stories on the news or horror stories from friends and family. Their solution to conquer their fear is to do their research. Fear of the unknown is lessened when armed with knowledge.

Instead of ridiculing patients who advocate for themselves, we should be praising them. Many patients could choose to ignore their symptoms and problems. They can refuse to be educated (as many of us have experienced). Instead, they choose to learn and understand. By refusing to acknowledge their efforts we are setting the patient against us. Think about it. Do you like to be told that you’re wrong?

I feel the best way to address this with patients is first to acknowledge them.

“I appreciate that you’ve taken the time to do your research.”

“I think it’s great you take this so seriously.”

Then address the problems with self-diagnosing through the internet. Take it a step further by providing with the appropriate resources.

“Unfortunately, the sources you’re using aren’t very reliable. Here are some resources you can use to get a better idea of what’s going on.”

The biggest issue arises with a misdiagnosis. I’ll use myself as an example. When I lived in China, I developed severe abdominal and back pain. Multiple visits to the ER, even a CT scan, yielded no answers. Frustrated, I took to the internet and found a diagnosis to consider – pancreatitis. At that time, I wasn’t involved in medicine. I didn’t know it was unlikely that I had pancreatitis. I just knew that the symptoms sounded right. So I booked an abdominal ultrasound (since you don’t need physician orders in China, just the money to pay for it).

The ultrasound technician found the problem immediately. My gallbladder was filled with stones. I was, of course, surprised. I barely knew what the gallbladder was, let alone that it could be filled with stones. I accepted my diagnosis gracefully and followed the doctor’s instructions.

Some patients may not be as willing to let go of their diagnosis. They may have made their own differential diagnosis or gone through tests before without answers. Again, acknowledgment is the answer. Acknowledge their concerns. If their diagnosis is very unlikely, explain why they might have been misled and why you don’t believe they have this illness. If you don’t have a diagnosis yet, explain how the testing may rule out the patient’s diagnosis. Patients don’t understand the process behind your decisions. Keeping them informed eases their anxiety and builds trust between you.

I sound like I know what I’m talking about, but of course I’m not a practicing physician. I don’t get to put this into practice as much I’d like. The idea came to me after reading In Shock, which focuses on speaking to your patient with respect and compassion. Dark humor and making fun of people become common to deal with stress, but at the end of the day patients deserve to be treated with respect. I’ve been trying to adjust my attitude and the way I deal with patients to reflect that. It takes time, and it is difficult to avoid joining in to the general attitudes of other healthcare employees.

How do you deal with patient who rely on internet research? Are you guilty of belittling patients for googling their symptoms? Do you disagree with my suggested approach?