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Monday, September 26, 2016

Hearsay

ldquo;Believe half of what you see and none of what you hear.”

A few years back, I was in clinic and went into a room to listen to a patient's heart sounds (*details changed to protect anonymity). A resident physician working with me that day had already seen the patient first. Before I entered the room, he'd described everything about the past medical history including an “easily audible” heart murmur. Even though it was pretty straightforward, I still wanted to listen. And so I did.

“It is an early peaking, systolic murmur,” he said as we walked up the hall, “radiating to the carotids. But super loud.” That description was suggestive of a narrow aortic valve. I figured that a murmur this loud had been assessed with imaging in the past.

“Did she get an echocardiogram?” I asked. The 2-dimensional ultrasound of the heart, or echocardiogram, visualizes the blood flow and the heart valves. Though the physical findings lead us to where we are going in heart disease, actual images tear the roof off of the sucker to confirm things. The clinic was busy. And this was an upper level resident. So I cut to the chase. I wanted the echo results.

“She did,” he replied. “I need to double check the final read but I'm pretty sure it confirmed aortic stenosis.”

“Do you know how severe?”

“No. I'll have to look again when we go back into the room. But I know she doesn't have any symptoms, which is good.”

“Yeah.”

So he went on to tell me a few other things about her before we reached the room. After a quick knock, we entered the clinic room together. Nothing about it was unusual.

“Hi there, ma’am. My name is Dr. Manning and I'm one of the senior doctors in the clinic working with your doctor. We always put our heads together about your health and figure 2 brains are better than 1.” She smiled and I smiled back. After a quick review of her concerns and the plan of care, I reached into my pocket to pull out my stethoscope. “Mind if I listen to your heart?”

“Not at all,” the patient replied. “Guess 4 ears is better than 2, huh?”

I chuckled and nodded while placing the rubber tips of the stethoscope into my ears. And honestly? I wasn't even thinking too hard when I did that. I reached over to her chest and searched the classic listening areas, aortic, pulmonic, tricuspid, and mitral, with the cold diaphragm.

Sure did.

The whole “not thinking too hard” thing wasn't because she didn't matter. It was just that I'd heard the story and exam already, including the echo results. This was mostly a formality, honestly. I even made a comment about the pretty necklace she was wearing as I slid it out of the way to reach her chest. The patient began sharing that she'd splurged on it during on a vacation once and how she hasn't removed it since. I raised my eyebrows and nodded, then lifted one finger to let her know we'd need to hit the pause button for a few moments.

You know. So I could hear the murmur that already had a diagnosis.

And so. I lean in and quickly listen. And just like that, I recognize that what I was hearing isn't at all what had been described to me. I raised my eyebrows. “What did you say this murmur was from?”

“Aortic stenosis.”

I squinted my eye and listened again. “Hmmm. This murmur sounds diastolic to me. Hmmm.”

“She definitely has aortic stenosis. I heard a crescendo-decrescendo murmur. And it was during systole.”

“Okay.” I carefully listened again. I then felt the patient's pulse and listened some more while timing it out with the rhythm of the heart. And still what I heard sounded like the flow of turbulent blood during the relaxation phase of the heart cycle. I listened some more. And then once more. “Aortic stenosis, huh? Okay. I guess my hearing is off today.” And that was that.

I conceded since I knew that the imaging supported his assessment. But honestly? That murmur sounded nothing like what he was saying to me. The whole thing made me uncomfortable, especially feeling so off on something like this, a bread and butter physical finding.

“Yup. Stenosis. But let me just confirm how severe, okay?” He pecked into the computer and clicked a few screens. And while he did, the patient asked a few questions.

“Is my heart okay?”

“Have you been told about your heart murmur?”

“Yes'm.”

“We're just talking about your heart murmur. That's just the flow of blood rushing over your heart valves. Have you been lightheaded or dizzy?”

“Naw. Never that.”

“Okay. We're just checking to see how narrow your heart valve is but it sounds like this is an old issue, okay?”

“Oh alright then.”

She asked a few questions about aortic stenosis and what that meant while he moved through screens to confirm for me the final reading on the echocardiogram images. Since I was less occupied, I pitched in and explained. Even though my ears were telling me of a different diagnosis.

Yeah.

So as we discussed all of that, suddenly I notice a funny look on the resident's face. “Oh must've misread that,” he mumbled to himself. “Um, Dr. M? It's actually moderate to severe aortic regurgitation.”

He said that right after I'd finished my soliloquy on aortic STENOSIS and right after I'd finally talked myself out of what I knew to be true based upon what I'd heard with my own ears.

Shit.

And no. It didn't turn into a big thing with the patient at all. I apologized and told her that I'd misspoken and that her heart murmur was more of the kind you get form a leaky heart valve instead of a narrow one. My face felt like it was a million degrees. She laughed and said, “I was wondering. I been told before my valve was leaky. I ain't never heard of it being stiff and narrow before so that was news to me.”

Sigh.

So here's my point of telling you all of this:

The things that happen to me at Grady are simply metaphors for life. Trust your gut and what you know. Listen with your own ears and then listen again. Believe your ears, especially when they've heard a lot of things. Same goes for your eyes. But especially believe yourself even when odds stack against what you think. That is, when you feel sure.

I doubted myself. And honestly? It wasn't even a soft call. I felt embarrassed for my initial instinct to doubt the echo report when I shouldn't have. I shouldn't have at all. Plus, I hadn't seen that echo result with my own eyes. That's a lesson, too.

And no. I am not always sure. But this time I was. And I'm still mad at myself for not laying down my nickel and betting on me. I recognize it's okay to be wrong. But I think my “ah hah” moment is in that I need to be just as okay with being right.

Does this even make sense?

As for my resident, I gave him some feedback. I'm pretty sure he, too, convinced himself of what he heard based on what he thought the images showed or could have just been so junior that he misjudged what he heard altogether. So yeah, I gave him feedback right away. But as I did, I showed my own clay feet and revealed what I'd done wrong as well. I'm senior to him yet I needed him to understand that even after 20 years of being a doctor, we are still works in progress. I let him know that being scared of looking silly isn't a good reason to not push when you feel pretty sure. And mostly, I was sure, even though I was being told otherwise. I was just two seconds away from saying, “Well, I don't know what that echo is saying, but this murmur isn't consistent with aortic stenosis at all.” But I didn't. After all, the echo said it was aortic stenosis.

That is, until it didn't.

Yeah.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Thursday, September 22, 2016

A message to all of those eager young medical students and residents who want to 'transform health care'

Living in the fine city of Boston, I am fortunate enough to be located right in the middle of a medical hub. A place that's full of exciting new research, developments and ideas. Working at the frontline of hospital care, also with a keen interest in quality improvement, patient experience, and technology, I frequently attend social and professional healthcare networking events around the city. While doing this, I've gotten to meet a lot of interesting, diverse and ambitious people. But there's a trend I've noticed among many students and resident physicians who are interested in health care policy and technology in particular. It's the phenomenon of a young starry-eyed future doctor who has barely even started their career yet (typically still in medical school), who expresses their desire to “completely transform health care.”

Yet when you speak a little bit more to these well-intentioned folk, you realize that they want to do it from as far away as possible from the front lines of clinical medicine! From my experience, Boston has hundreds of these types of people floating around. Whenever I meet them (and don't get me wrong, they seem sincere and pleasant enough), I'm amazed by how brazen they are in their assertions about what's wrong with health care and what we need to do to “change things”. They are also the most enthusiastic about how great the proliferation of information technology, through Meaningful Use, has been for health care and how the last decade has really improved things for patients (go figure). My advice for them is always the same:
• Sure, it's awesome to have high and lofty ambitions. But if you're still in medical school, focus on becoming a good and competent doctor first and foremost.
• Never lose touch with the front lines, no matter where you intend to be 1 day.
• Remember that without doctors (and nurses) on board, “change” in health care is meaningless. Listen to them, because their perspective—along with of course our patients—is paramount.
• There is a reason why health care (in almost every country) has very big problems that need to be addressed. It's a complex beast. No overnight or easy solutions exist.
• Wherever you go, your best and most meaningful career moments and highest job satisfaction will likely come from those special moments when you are just being a good doctor. This can't be recreated in many other jobs, so never look towards the bigger picture so much that you fail to see how much difference you can make in the trenches of everyday medical care. Medicine is a uniquely personal and emotional arena, with humanity, compassion, and empathy at its core.

In short, don't try to save the world from afar! I always remember a quote by Dag Hammarskjöld, the Swedish economist and author who is widely considered to be the epitome of a true global diplomat. If you don't know very much about Mr. Hammarskjöld, his life story makes fascinating reading. He was a man of great integrity who worked tirelessly on several peace projects after World War II. He served as the Secretary-General of the United Nations, but sadly died during his term in a plane crash in 1961. He was posthumously awarded the Nobel Peace Prize and John F. Kennedy called him “the greatest statesman of our century.” Considering the turbulence of the first half of the last century, that's quite an accolade. Many wise and thoughtful quotations are attributed to him, some of which are actually very relevant to medicine and health. One of them is about how “constant attention by a good nurse may be just as important as a major operation by a surgeon”.

Hammarskjöld was a man who understood the nature of humans and the complexities of our world. This particular piece of advice applies to any doctor who is wondering what's the most essential and worthwhile thing to be doing. He said: ”It is more noble to give yourself completely to 1 individual than to labor diligently for the salvation of the masses.”

If there's ever any question about what the higher cause is—striving to save the world or just being a good doctor—the answer is right there. It is always selflessly dedicating yourself to your patients.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Wednesday, September 21, 2016

Palliative care is our responsibility to patients

This week we had an all too common clinical situation. A patient with severe chronic obstructive pulmonary disease (COPD) developed pneumonia. His prognosis because of his underlying disease is relatively poor.

Fortunately, the patient and his wife had previously discussed resuscitation and intubation. He does not want to go down that road. Because of this conversation we quickly went down the road to palliative care.

As we explained to the patient and his wife, we will treat his pneumonia with appropriate antibiotics, but we will also treat him. Sometimes in medicine we forget the patient. We focus on the disease or the prevention of a disease. But patients want us to treat them. They care about how they feel and that they are suffering.

The palliative care movement reminds us daily that we must focus on the patient at least as much as we focus on the disease. But often the patient's needs trump the recommended treatment of the disease.

Palliative care is truly patient-centered. It is family-centered. Palliative care brings humanity to medicine, a humanity that we risk forgetting. When we start medical school, most medical students come wanting to focus on that humanity. As we go through school and residency, and even in practice, we can become enamored with the science and treatments. Palliative care reminds us to maintain a balance between the science and the humanity.

We are fortunate to have palliative care physicians to remind us. We should not need that reminder, but we do. So we should all thank those dedicated physicians for helping us maintain our moral compass.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Tuesday, September 20, 2016

Are doctors paid too much?

Years ago on Cape Cod, my kids and I stumbled across a man who had spent the day creating a sand sculpture of a mermaid. It was an impressive piece of art. “How long did it take you to make it?” we asked. While I can't recall his precise words, the response was something like “25 years and 7 hours”. I'm sure my astute readers will get his point.

We become transfixed watching Olympic athletes as they performed in Rio. So much depended upon their brief routines, which can last seconds to a few minutes. While a diver's acrobatic plunge may take 2 seconds, it would not be fair to leave aside the years of work and training that prepared the athlete for this moment.

The same point can be made for anyone who has worked and trained hard to reach a point where the action performed seems easy to a spectator or a customer. If an attorney prepares estate documents, we can assume that the fee for this reflects the prior training and research that the lawyer has done on this issue, as it should. If an appliance repairman, by virtue of his expertise, fixed our ailing washing machine in 5 minutes and charged us $100, should we balk at this price gouging? If a less skilled competitor spent 2 hours before finding and correcting the glitch, would we feel better about handing over $100? Is this fair? A musician doesn't just wake up 1 morning and hop onto a stage to give a concert. When we pay to listen to an artist perform for 2 hours, we are likely listening to the product of years of grinding work, disappointment, innovation and discovery.

I believe that this same principle applies to my own profession. Over the years I have heard patients complain about various medical charges and fees. While we all know that there have been excesses, many of their gripes are misplaced, in my view. It's not fair to equate the medical fee with the time that the physician expended on providing your care. A cardiac bypass operation takes just a few hours. A colonoscopy takes 10 minutes. Treating a patient in an emergency room with a drug overdose may take just a few hours. A psychiatrist might guide a suicidal patient to choose another path in half an hour. A spine injection to relieve chronic pain takes only a few minutes. A dermatologist recognizes a suspicious lesion in a few seconds. A seasoned surgeon tells an anxious patient after a 20 minute consultation that surgery is not necessary.

Often, folks who make us all look easy are fooling us. If we think it's as easy as it looks, then we're the fools.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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