From the Editor
There is something often dehumanizing about the health-care experience – the way patients can be reduced to medical-record numbers, the way lives can be summarized in disease names and a few demographic details (“a 30 year old woman with schizophrenia”).
This week, we consider two essays that are about people who happen to be patients – and the lessons that our colleagues have drawn from their stories.
In the first selection, we look at a paper written by Dr. Taimur Safder that was published in The New England Journal of Medicine. It’s about the name of a dog – and much more. During his training, Dr. Safder presents the case of a person who develops chest pain when walking his dog. When the supervisor asks the name of the dog, the physician isn’t sure. “Four years later, I’m not sure anything I’ve carried from residency has been more useful than that question.”
No, this Reading isn’t really about dogs
And, in the second selection, we consider a short essay by Dr. Lee Lu. The Texas doctor describes her experiences working with a patient with substance use problems – and wrestling with her own biases.
Finally, returning to the topic of cannabis legalization, we consider some responses to last week’s Reading, and a CMAJ editorial on the topic.
Care and Connecting
“The Name of the Dog”
The New England Journal of Medicine, 4 October 2018
It was July 1, my first day of residency, and a queasy feeling lodged in my stomach as I donned my new white coat. It was different from the previous ones I’d worn — not just longer, but heavier. I was carrying in my pockets everything I thought I needed as a freshly minted doctor: my three favorite pens, a glossy Littmann Cardiology III stethoscope, copies of studies related to my patient with cirrhosis, and of course my trusty purple Sabatine’s Pocket Medicine.
Before the day was over, my bodily-fluid–covered white coat would have made a fitting prop for a CSI episode, my attending physician wasn’t nearly as impressed as I’d hoped with the studies I waved in front of her, and worst of all, I had lost all three of my pens. But with the aid of my pockets, I’d gotten through. I’d played my part reasonably well most of the day, but the moment when my attending had brought me up short with a question kept replaying in my mind. During morning rounds, I had presented a patient who was admitted for chest pain after walking his dog. My attending had asked, ‘What was the name of his dog?’
I was stumped. Worse, I didn’t know why we needed to know. Nowhere in the books or the studies I’d read had a dog’s name contributed to the differential. But the attending took us back to the patient’s bedside and asked. ‘Rocky,’ the patient said. And there followed a brief conversation that was more colorful than any other I’d had with a patient that day. It led to a transformation I did not fully appreciate at the time: there was an actual person behind that hospital-issued gown.
Four years later, I’m not sure anything I’ve carried from residency has been more useful than that question.
So begins a short essay by Dr. Safder.
He notes how the dog question led to other questions:
It’s because of that question that I found myself discussing the plot of a Spanish soap opera with another patient, a show I found him watching every morning. We even had company sometimes, when the translator would join us and explain the murder of the stepson by his twin brother or some other complicated event. Later, the patient and I would have difficult discussions about his immigration status and what it meant for his treatment plan. But I like to think that because he and I were fellow witnesses to an evil twin’s murder, he had faith in me when I asked him to trust our medical team as we did our best to get him the care he needed.
He notes his success at connecting with patients. “Soon we signed a treaty under which I would read the ‘studies’ she brought in about black cherry and milk thistle and she would start taking one new medication every 2 months. We started with an ACE inhibitor.”
Dr. Safder describes the lives and deaths of some patients he had worked with before concluding:
It is easy to lose sight of yourself during residency, as you endure the countless hours spent in windowless rooms entering data in electronic medical records or completing administrative tasks or juggling a dozen other competing priorities. But if I may offer one piece of advice to my new colleagues who don a long white coat for the first time each July: Make sure to get the name of the dog.
A few thoughts:
- This is a great essay.
- Dr. Safder wrote this piece for doctors, and it was published in an American journal. That said, his advice is good for all of us clinicians, regardless of geography.
- Thinking back to my own training, I can remember Dr. David Goldbloom stressing the importance of gathering identifying data at the beginning of the interview – not simply to obtain basic demographics, but as a way to understand where patients are coming from, and some of their struggles. It was and is excellent advice.
- On a tangent, the name of the dog pictured above is Toulouse. He’s a volunteer pet at CAMH, where I work, and visits inpatient wards a couple of times a week. He also has an Instagram account with 192 followers (not bad considering social media’s inherent bias towards cats – and, yes, I’m joking).
Care and Bias
“To Walk in Another’s Shoes”
Annals of Internal Medicine, 21 August 2018
Finishing the progress note on my last patient, I realized it was already 11:45 a.m. My medical student had not come out of the exam room yet. I waited for another 5 minutes and then knocked on the door. The student opened it and signaled to me that she would be out in 5 minutes. She finally came out of the room, looking exhausted. She started to present the history of our patient, Ms. H.
‘This is a 50-year-old female with a history of substance abuse with intravenous ‘speed,’ endocarditis, and left hip septic joint status post removal of left femoral head, here for pain medication refill. She was recently discharged from the hospital from the orthopedic service. Her left hip pain is severe. While in the hospital, she had been very demanding and had refused physical therapy unless she received more pain medication. Social history was significant for her occupation as an exotic dancer and a ‘madam’ and drug abuse.’
The medical student proceeded with the review of systems and physical examination. How should I approach this patient? I had to stand firm given her high-risk behavior.
So begins an essay by Dr. Lu.
In this short, honest piece, she describes her own biases.
As I listened, tears flowed down my cheeks. She had endured a harsh life. This time, I saw not just her sincerity but also her determination. I rechecked her urine, which was negative for all illegal substances except the opioid I had prescribed.
With all the opioid abuse and overdose, more restrictions are being placed on physicians to prescribe these agents responsibly. Our first instinct is to say ‘no’ to all patients with pain who have identifiable risks for addiction and do not have cancer. But a new dimension was opened up to me. Ms. H showed me my bias toward patients with history of illegal drug abuse. More important, she showed me the trust that can exist between a physician and her patient.
A couple of thoughts:
- This is a great essay.
- The honesty of this piece is admirable. We all have our biases – but it’s difficult to acknowledge that.
Care and Cannabis
Last week was a big week with the legalization of cannabis. The Reading considered my new podcast on the topic (just 11 minutes), as well as some relevant papers from the journals.
Readers were quite praising of the podcast. One wrote simply: “awesome.” Another commented: “Crisp, lively, to the point…” An ED physician liked the podcast, but suggested that capsaicin (a chili pepper extract) was a better treatment for cannabinoid hyperemesis syndrome. “While ginger may be nice, it does not appear to have any evidence to support its use in CHS and does not appear in the treatment protocol that was recently published by Lapointe et al.”
Legalized cannabis: not just last week’s news
But if our colleagues were excited about the podcast, the legalization drew a more mixed response, with some worrying about a possible surge in cannabis use.
On this topic, CMAJ Editor Diane Kelsall weighed in with a thoughtful editorial, “Watching Canada’s experiment with legal cannabis.”
Noting the rise of new producers, she notes: “Their goal is profit, and profit comes from sales – sales of a drug that, according to Health Canada, will cause a problem in nearly 1 in 3 adult users and an addiction in close to 1 in 10, with higher risks in youth.”
She makes several suggestions, including: “The anticipated windfall of tax revenue should fund research on harms related to use, as there are many unanswered questions about the short- and long-term implications of cannabis use…” And she suggests that the effects of the legislation be carefully watched: “[I]f use of cannabis increases, the federal government should have the courage to admit the legislation is flawed and amend the act. Canadians – and the world – will be watching.” Regardless of your opinion of the legislation, measuring its impact seems sensible.
You can find the editorial here: http://www.cmaj.ca/content/190/41/E1218.
My new podcast on the clinical consideration of cannabis legalization can be found here: https://www.porticonetwork.ca/web/podcasts/quick-takes/cannabis-oct2018.
And last week’s Reading, which includes a list of major papers on cannabis (tapping The New England Journal of Medicine, JAMA, and other journals), can be found here: http://davidgratzer.com/reading-of-the-week/reading-of-the-week-cannabis-legalization-clinical-implications-major-papers/.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.