Can We Really Understand Our Patients?

The following post originally appeared on Medscape’s The Differential on January 12, 2011.


Knowing I had recently completed a rotation in OB/GYN, a friend asked me how they (medical schools) make male medical students understand what their pregnant patients feel like. It was an interesting question. And it got me thinking about understanding what our patients go through – no matter their age, or sex, or condition.

As medical students, there is not much discussion about how our patients feel. Sure, there are classes about human suffering. But these classes deal with generalities. Each patient experiences their condition in their own unique way. To draw upon the obstetrical cases, telling a woman that she is pregnant can be met with a variety of responses that range from fear and dread to joy and elation.

I once heard Dr. Wil Alexander say, “The moment a symptom occurs, a story begins.” Those words seemed so profound at the time that I wrote the idea down and saved it. Each patient who walks through the hospital doors is more than a symptom. They are more than a diagnosis. They are more than a disease. They are human beings who have a story – a story that is just waiting to be told.

The question that my friend raised, regarding how male medical students are made to understand the experiences of their pregnant patients, made me realize that there is little done to help us understand our patients’ experiences. But I am okay with that. Because each experience is too individual to explain away with a blanket statement. It is impossible for anyone to know exactly how another feels.

The important thing, in my opinion, is for us to connect with our patients and convey that we acknowledge that they are going through a difficult or trying situation and to offer ourselves as they cope with it. It can be something as simple as giving them permission to be candid about their raw emotions – the frustrations and fears that build up – in a safe environment where no one will betray their trust or judge them or treat them any differently because of it.

It would probably be a good thing if we could understand exactly what our patients were experiencing. It would probably help many of us with our empathy. But without that ability to understand perfectly the experiences of our patients, we are left with the ability to accept perfectly the experiences of our patients. And I suspect that for most of them, this much is enough.


Well hello there, stranger.

Been a while since I have posted much on here. It’s just been really busy lately. I completed the 10 week block of Internal Medicine just over a week ago. Since then I’ve started a 4 week block of Neurology. So far it is a drastic change of pace. I should be posting something here in the next week or so — at least that’s what I am hoping for.

I am also working on replying to some emails. If you have emailed me through the Contact page, I apologize for being slow the reply. I appreciate and welcome all feedback — even the negative ones. Yes, I have had some rather confrontational emails, but oh well. Such is the nature of internet anonymity, right?

Also, if you are a longtime visitor you will notice a bit of a change in the sidebar. I am not sure if it will be there very long or not. I decided to add this site to the Google Friend Connect system. I am still unfamiliar with what it does. I assume it helps you keep up to date with the blogs you follow. At this point I had relied solely on Feedburner to syndicate the blog posts for whoever is interested. But technology marches on — and I guess I will eventually follow.

Other than that, this post is just to update ya’all out there about what’s going on. If you’re interested, I have also started blogging again at The Differential. So stop on over there and say hello too!


The Humanity of Medicine

The following is a post I wrote for Medscape. It was published on their The Differential blog on January 30, 2009.


I received an email this week regarding an essay contest. The first place winner would receive $1000 and the top three essays would be published in the AAMC’s Academic Medicine. (This is the Gold Foundation’s 2009 Humanism in Medicine Essay Contest.) This year’s essay is to be a reflection on the following quote by Anatole Broyard:

To most physicians, my illness is a routine incident in their rounds, while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity.


As I read that quote in the email I paused. I thought it simple, yet profound. And although I deleted the email, thinking my chances of winning an essay contest too slim to bother with, I quickly copied the quote and added it to my growing collection (a 41-page Word document consisting of just over 14,000 words).

The idea behind this quote is simple, really. It challenges those of us in (and going into) the medical field to remember what it feels like to be on the other end of the stethoscope — to remember that there is a person and not just a pathogen infecting a host. I remember a course in my freshman year called Understanding Your Patient. The course was not that hard. We talked about teaming with our patients. We talked about how to bring up tough subjects. We tried to learn how to step into their world.

Later in the sophomore year I took another course called Art of Integrative Care. This class challenged us to go deeper into the lives of our patients. The entire quarter was spent investigating and discussing how to practice Whole Person Care by addressing the spiritual health of a patient while we cared for their physical well-being. One assignment for this class sent us into the hospital to interview a patient. We weren’t there to investigate their physical ailment. We were there to get to know the patient, how they were coping with illness, where they found strength, and how (if at all) the illness had affected their belief system. How much more personal can a healthcare provider get than when talking to a patient about their fears and insecurities, their beliefs and doubts, about why bad things happen, and their hopes and their dreams?

What struck me is that this course just ended one month ago, yet the ideas I heard have somehow slipped away from the surface. I attended clinic today at a Pediatrics office. Thinking back, I remember times when I didn’t even bother to consider what the patient was feeling. I walked into the room following the attending, smiled and said hello as I was introduced as the medical student, and listened intently to the patient (or the patient’s mother) as the symptoms and complaints were recalled. My mind raced to form a differential in case I would be asked a question regarding the patient. In that frenzy it became all about the disease. I was desperately intent on meeting and beating the microbe.

But there were also times when the attending walked out of the room to go get something. During one of those times I found myself looking across the room into the eyes of a young patient and her mother. Maybe it was just to avoid an awkward silence. Maybe I didn’t want them to think me totally inept or socially retarded. Or maybe it was that a part of me wanted to connect with the people on the “other side.” Regardless of the reason I, the self-proclaimed king of introverts, spoke up. I engaged the little patient. We talked. She laughed. Her mother smiled. She told me that her mother had lots of sisters but she only liked one. She giggled. Her mother laughed. I chuckled.

We all left the room knowing what the diagnosis was and what the treatment would be. More importantly, I left the room knowing that I had met the patient and not just the disease.


Why Bother Learning Something We’ll Lose?

Originally posted on The Differential on July 30, 2008


During high school I took three years of Spanish. I thoroughly enjoyed it and really wanted to spend a year abroad to become fluent with the language. Unfortunately, when I got to college, I desperately wanted to finish in four years. My year abroad ended being sacrificed. In my final year, I did take Spanish 101 and 102, more for the fact I knew they would be easy A’s.

Two years removed from graduation, I’m sad to say that I feel I wasted all that time studying Spanish. I haven’t used it at all. Sure, I might remember some words and phrases here and there. I can probably still conjugate the present tense of most regular verbs. But I can’t remember the vocabulary. I turn on Spanish television and I get nothing. Well, the actors are pretty dramatic, so I suppose I can get something.

The other day I was standing in line at the Argentinean Consulate when the lady behind me started talking to me in Spanish. I looked at her, puzzled. She repeated her question. I tried to piece together what she was saying but the only thing I got was “Koreano.” I assumed she was asking if I was Korean. Well, I finally apologized and told her I couldn’t speak Spanish after which the conversation ensued in English. But I couldn’t help feeling frustrated that I couldn’t even understand a simple question after more than 3 years of Spanish classes.

Language is just one of the things that you have to use, or else you lose it. And this got me thinking about medical training. This year, as with most first year medical students across this country, I took General Anatomy. As far as I know, I won’t have any anatomy classes during second year. But Step 1 of the USMLE exam will cover General Anatomy. It worries me that I will go through an entire year without ever having an Anatomy lecture. I guess I am going to have to continually review myself whenever I find myself with that elusive “free time.”

I also thought about the practice of medicine. This year, I heard a talk by a cardiology resident. He said that while he was tempted to go into surgery, he found the clinical skills of surgeons to be lacking. Most wouldn’t be able to properly auscultate a patient. He had chosen cardiology because the cardiologists he had witnessed all impressed him with their clinical abilities.

One could debate the merits of having surgeons equally competent in wielding a stethoscope as they are with scalpels. It is probably not really important for surgeons to retain this skill. After all, they are called in to do their specific job — to cut open a patient and fix an immediate problem. If a patient requires auscultation, then his or her internist should be able to do this or refer the patient to a cardiologist.

But doesn’t it seem like a waste of time, money, and — well — medical training to just let a skill atrophy? Would time in medical school be better spent training students in the specific specialties they are interested in? Why bother teaching a student proper auscultation skills if the student is heading into Ophthalmology? I wonder, is there a better way to train our doctors of tomorrow?

In his book, Complications: A Surgeon’s Notes on an Imperfect Science, Dr. Atul Gawande writes of Shouldice Hospital in Ontario, Canada. The surgeons there are experts at hernia repairs. That is all they do. Day in and day out, the doctors do nothing else but repair hernias. What may be surprising to most American medical students is the backgrounds of those who operate at this clinic. A few of them have never even completed a surgical residency. But they have trained extensively at repairing hernias. This clinic, Dr. Gawande writes, has a far higher success rate for their operations than any other place in the world. Why? Because they only do one thing, and they do it amazingly. Can this be applied to medical school to cut down on the massive amounts of information that medical students are force-fed each day?


My Fair Doctor

Originally posted on The Differential on July 23, 2008


My little sister has been on a classic film spree. She announced to me that she wanted to see all the movies that had won an Oscar for best film. She also bought an Audrey Hepburn 3-Pack DVD that contained Breakfast at Tiffany’s, Roman Holiday, and Sabrina.

Okay, I’ll admit that I too am a fan of Audrey Hepburn, Julie Andrews, and other great actresses of Hollywood’s golden era. They seem to convey so much in the subtle facial expressions or tone of voice -– something that I fail to notice with so much CGI/special effects these days. Well, being the awesome big brother that I am, I used my Netflix subscription to order another one of Audrey’s famous films: My Fair Lady.

At almost three hours in length, My Fair Lady is a pretty long movie that traces the journey of a poor flower girl as she is transformed under the instruction of Professor Higgins into a genuine Lady. The process is long and arduous. It’s filled with frustration as well as comical moments. The audience watches as Eliza Doolittle sheds tears and then as she recites phrases like “The rain in Spain falls mainly in the plain” or some other nonsense about hurricanes in Hereford and Hampshire trying to properly emphasize each syllable to the professor’s satisfaction.

It’s sort of like the transformation that is required of medical students. They say medical school changes you. It changes the way you think, speak, and act. It changes who you are. And it’s supposed to do exactly that. It takes the raw material in the form of an eager, optimistic, and sometimes-naive college graduate and transforms it into a newly minted MD who is probably more than just a little nervous about starting internship.

During orientation and registration our school administrators told us that by the end of just the first year we would notice things differently. We would see and hear things through different lenses.

I am kind of surprised at how true that statement turned out to be. There are words and phrases now floating around in my noggin that I never knew existed.

Mnemonics wander idly through my mind. Sometimes I don’t even remember what they are for. There are words like “LARP” (describing the path of the Vagus nerve) and phrases like “army over, navy under” (suprascapular artery over and nerve under) and “To Zanzibar By Motor Car” (branches of the Facial Nerve).

Prior to the first year, I had never heard of the phrase “differential diagnosis.” Well, on second thought, I did often hear Dr. House ask his team what the differential was. But it kind of flew over my head at the time.

Evidence-based medicine now means something. Before, it just sounded cool. I was a science major. I knew that evidence was good. Now, I still think it’s good. But I’m not too fond of searching through the literature for the latest studies trying to determine a link between statins and preventing Alzheimer’s disease.

Whenever I go to a restaurant I watch the waiters. Why? Because in Anatomy class I kept hearing about a waiter’s tip that can present with injury to the upper roots of the brachial plexus. I still have yet to see a waiter walking around with the so-called “waiter’s tip.” But it hasn’t stopped me from trying to find one.

Wal-mart is no longer just a convenient place to pick up supplies. It’s also a great place to pay close attention to customers’ faces and gaits. I might be able to identify a walking example of some neurological deficit I learned about in lecture.

As far as medical education goes, I’m just a baby. Or, to tie in with my intro, I’m just starting my training with the good professor. I’m still raw and crude. But even after MS1, I’m glad to report that there’s progress.

In about a month, right after Labor Day, my second year will officially begin. I’ll try to enjoy my last “free” summer. In the meantime, like Eliza Doolittle, I’ll try to faithfully recite the precious tidbits of information that the dear professors have imparted. However, it’s probably a little bit harder than talking about rain falling on Spanish plains in that oh-so-elegant British accent.


A Thank You Note

Originally posted on The Differential on July 17, 2008


Dear Professor,

Medical school is filled with plenty of defining moments. During my first year, one of those moments was meeting you. I’m not quite sure what word I’d use to describe that time I first met you. Odd? Eerie? Creepy? Awesome? Inspiring? Solemn?

I remember looking at you, a little intimidated. You were the expert in what you were going to teach me. I was a little lost as to what I needed to do. I noticed your wrinkled skin. You could probably tell me a whole bunch of fascinating stories from your lifetime.

A classmate mumbled that you were old. But you looked calm and composed –- not at all like a rookie teacher. It was reassuring. I knew I’d learn a lot from you during the course of my first year.

I remember staring at the muscles of the neck in Anatomy lab. I was confused about which muscles were which. Was this the anterior scalene? Or was that the anterior scalene? If this one is the anterior, then that must be the middle. But wait, what the heck is this muscle here? Staring into a human neck for the first time can be disorienting. And it often only barely resembles the drawings in Netter’s Atlas. I lamented, but you offered no answer. Instead, you remained silent, forcing me to figure it out on my own. And when I finally figured it out, I thought I could make out the beginnings of a smile on your face.

Because I struggled, I remembered. And I did well on that first anatomy lab practical.

The rest of the year followed in similar fashion. I was stuck and confused. You stuck to your teaching method. At least you were consistent. Regardless, you stayed right beside me all along.

I came to accept your method of teaching and even found your silent presence calming — even if I often wished for you to just speak up and point out what I was looking for.

I just wanted to write this note to say thank you. I’m sorry you will never get to read this. At the memorial service we held for all those who had donated their bodies to our Anatomy program, I sat quietly and looked around. There were plenty of family members there to remember and celebrate their loved ones. I couldn’t help but wonder if your family was there.

Was it that old lady wiping away tears? Was it the young lady who sat proudly as her loved one was appreciated by so many students? I don’t know; I’ll never know.

I never knew your name. But I knew your face. I knew your arms, your hands, and your legs. I knew you inside and out. And I know that you have give 100% of yourself so that I could be a better doctor. Thank you, Professor.


It’s High School — With Scalpels

Originally posted on The Differential on July 9, 2008


It’s lunchtime at the hospital cafeteria. Patients stand in line, their IV stands in tow. Children from the pediatrics hospital sit in pillow-lined wagons while their parents pick out food. Doctors, nurses, and other staff members file through the cashier, scanning their cards so as to avoid the hassle of carrying cash. The first year medical students eat and talk about their morning experiences on the wards, some more excitedly than others.

A phone vibrates and its owner chuckles as he reads the text message. And that’s how the lunchtime gossip starts. Or maybe that’s just how the morning gossip transforms into lunchtime gossip. He leans over to his neighbor, who then gladly moves the info down the line. A first year fainted during rounds that morning. Everyone smiles, then desperately tries to find out which one of their classmates fainted and on which service.

A character from Grey’s Anatomy said that the hospital is “high school with scalpels.” That could probably be said about medical school, too.

Watching at least one of the medical dramas on television seems to be a requisite for every medical student -– regardless of how little medicine is actually on the show. When the new season of Grey’s was starting, there were a bunch of my classmates who got together to have Grey’s Anatomy nights. (For the record: I don’t care for E.R., I have no comment on Grey’s Anatomy, Dr. Gregory House fascinates me, and Turk and J.D. never fail to, in the very least, put a grin on my face.)

In medical school you can find the nerds, the jocks, the popular kids, and the bullies. They’re just called by different names. For example, bullies have graduated to being called gunners. The really mean ones have an even cooler name: snipers (as previously written about by Anna on The Differential). Even the class elections, where interesting promises and platforms can be found aplenty, seem like popularity contests. It’s just tough to grow up.

On the other hand, I’ve heard plenty of stories about the workplace being so much like high school, too. Maybe it isn’t adults acting like teenagers, but teenagers acting like adults. And then we just have a bunch of really mature teenagers in high school. But this is a topic of a whole ’nother post.

The difference between medical school and high school, though, is more than just scalpels. It’s, uh, about… Well, it’s like… It’s about learning to save lives!

Wow. Now I’m even writing like a high schooler.