Tuesday, February 19, 2013
The things they don't teach in medical school
Al Franken, the humorist-turned-senator, once published a book that was titled "Oh, the Things I Know!" Indeed, by the time we reach parenthood, it is truly amazing what we keep up there in that attic of a brain. Here is a brief selection of things about the practice of medicine that I have had to discover for myself or never quite figured out, including clinical pearls, aphorisms, dictums, platitudes, mysteries and conundrums that have somehow found their way into my own cranium and are constantly trying to escape.
If you are called for a consult, don't accept the ostensible reason as it comes from the student, nurse or physician assistant. I have learned that rarely when I arrive is the problem what it was purported to be. As in everything else in life, nothing is as easy as it seems or as simple as it sounds.
Once you are out of your training, you no longer find yourself an object in the chain of blame. You have reached the pinnacle. But if you are not at a teaching hospital, you must devise a new paradigm. My own goes as follows: If anything goes wrong, first blame the patient. Then blame the equipment. If that doesn't work, blame the anesthetist, and if that doesn't fly, blame the nurse. And only if all else fails, blame yourself.
I have observed that all patients, even if moribund, look improved sitting up in a chair if the last time you saw them they were in bed.
How come they never teach you how to pronounce someone dead? My first day on the job as an intern, when I was called at 1 a.m. to do so, I had to improvise. After entering the vacated room (aside from the dead body) and certifying for myself that the patient had no pulse or respiration, I proceeded to pronounce: "By the authority vested in me by the Johns Hopkins School of Medicine and the New York State Board of Medical Examiners, I hereby pronounce you dead." I immediately heard raucous laughter from the nurses in the hallway, who informed me that pronouncement only required my filling out a form.
If you become a consultant, always remember what is expected of you. Consults are requested for two reasons only: "Please make this patient's problem go away," or "Please make this patient go away."
Why did they never teach you how to open one of those Johnson & Johnson Band-Aids with the red string? I always end up pulling it out.
Regarding the standard recitation of the physical exam, some things they teach you are just plain useless. If you ever see an adult patient in your office for a scheduled visit who isn't "normocephalic and atraumatic," go immediately and buy a lottery ticket. Such occasions are unprecedented and augur momentous events.
What in the world is "walking pneumonia?" I can't find it in my Principles and Practice of Medicine text and it doesn't seem to have an ICD-9 code. Maybe they'll put it in ICD-10. For that matter, I have never made a diagnosis of a "nervous breakdown" or "exhaustion" either.
Never ask a patient if he is feeling better before finding out if he has actually obtained and taken the medicine you prescribed. Otherwise you might say "I'm glad to hear the medicine is working," and receive the reply "Oh, I never filled the prescription," or, "I filled it but I was afraid to take it until I saw you again after I read the warnings."
The topic of how to charm a patient could occupy an entire post in and of itself. Here's one dictum I have developed: Humor always breaks the ice. If you are a male physician seeing a married man, make jokes at the expense of your wife. If the patient is a woman, make yourself the object of the joke, especially if you can quote your wife. If both husband and wife are present in the exam room, make fun of husband if you know what is good for you. Female physicians have to write their own rules, but Borsht-belt style humor is not generally required of them. As a matter of fact, I haven't any idea what women patients talk about with their female doctors, but I suspect the topic of husbands doesn't come up unless they are a problem.
If you are a specialist, when providing all hospital consults, visit radiology before you see the patient, not afterwards. You'll look smarter, do a better note, and you're going to have to go there anyway. I have learned over the years through great inconvenience not to follow the usual sequence of history, physical and laboratory data in gathering evidence that I was taught in school. As I tell my students, always visit the radiology department before seeing the patient in consultation. There is much that doesn't get into radiology reports. That way you won't have to change your opinion to accord with the facts after rendering it.
This is not a hard-and-fast rule, but patients over 60 can be addressed as Bob and those under 50 as Rob, unless they go by their nickname, which is usually their middle name. If so, enter that in your chart. It impresses patients if you know their nickname.
For further wit and wisdom, a great compendium of advice and humor that I wish to credit for inspiration, although I don't agree with all its advice, is entitled "Kill as Few Patients as Possible (and Fifty-Six Other Essays on How to Be the World's Best Doctor)" by Oscar London, MD, WBD, (the pseudonym of a retired internist) published in 1987 by Ten Speed Press and excerpted in Medical Economics. Perhaps you can find a copy on Amazon or eBay.
David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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.
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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.
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, 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
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 Richmond, Va., 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.
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.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
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.
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.
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.
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.
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David Katz, MD
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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.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
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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.
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.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.