Wednesday, March 14, 2007

Med Student

Today, we had several lecturers remind us of our "sacred" role as third year med students. In case we'd forgotten, they reminded us that our patients look to us for answers and appreciate the time we spend with them. Then, they reminded us how to interact with patients--don't forget to listen to what they're saying, and be empathetic.

I really doubt that most third year med students actually needed this lecture. (There are a certain few, however...) I would venture to say that most of my classmates and myself try our best to use our role as MS-III's wisely. I really enjoy my role as a third year student, and I have during this whole year. I carry fewer patients than an intern or resident, so I have more time to talk to each patient. As a result, I get more questions from the patients, and then spend more time answering questions, so my patients often know me better than any of the actual MD's. I have always treasured my role as a true advocate for my patients, and I have had many patients thank me. I know many (hopefully, most) of my classmates have had similar, equally rewarding experiences. I also know that, especially at [county hospital], most of my patients have been happy to have medical students involved in their care, because we spent much more time explaining things to them than the residents did (or the attendings, who pop in to say "Hi" and then fill out their billing card).

One of my first patients, back on surgery, came in with a "diabetic foot". Basically, she had a horrible abscess/cellulitis in her 4th and 5th toes that was threatening her whole foot, and because of her uncontrolled diabetes her immune system was kaput. It was a call night, and my resident was in a hurry when he evaluated her in the [county hospital] ER. "Ma'am, we're going to remove your toes, and I'll try not to, but we may have to remove your whole foot."

She flipped out.

The resident spent a few minutes trying to explain the situation to her, then left, both because he was frustrated and because he had to call the OR to get set up (and fill out her admit orders, and tell the ER to call bed control to admit her, and check on the other ER consults...). The other MS-III and I were left to examine the patient. She begged us not to take her foot. She was caught off guard, she said; she wasn't expecting this, surely it wasn't that bad.

We spent several minutes trying to calm her down. We assured her that no one wanted to take her foot off; that we would use our power judiciously in the OR; that we would do everything in our power to save her foot; but that if we had to do so, we would amputate her foot to save her leg, and perhaps her life.

After several minutes, the patient calmed down. "Oh, you two are going to make such good doctors! You have such great bedside manners! Not like that other doctor at all--he was so gruff!"

I seriously doubt that my class of med students is full of unusually empathic, kind people. What concerns me is what happened to the interns, residents, and attendings who get labeled as having a poor bedside manner. Sure, some of them had no social skillz when they entered med school, but the vast majority entered med school with a desire to help people. They also entered med school with the ability to talk to people, listen to people, and make human connections.

So what happened? Is it the lack of time that turns human beings into robotic interns? Is it the brutal call schedules that destroy doctors' abilities to interact with patients? Is it the constant exposure to human brutality, deliberate self-destruction, and great tragedy that turns doctors into automatons?

I have a lot of fear that I will become someone who can strike fear into a patient's heart and then turn around and leave, complaining that the patient should have expected her foot to rot since she didn't attempt to control her diabetes (in the resident's defense, the patient had prior surgery on her other foot for the exact same problem--this wasn't her first rodeo). I don't want to be so tired on call that I take poor care of my patients. I don't want to lose my humanity.

I am awfully glad, though, that my residency will most likely be in locations where medical students abound, so if I can't spend enough time with my patients, at least I can rely on the students.

On a closely related topic, one of the things that bothers me most about my current experience in family practice is that the doctors go on and on about how they "take care of the whole patient and the whole family", yet they spend less than 5 minutes per patient, often telling med students "focus on only 1 or 2 problems this visit". One doctor told me "be done with this patient in 10 minutes MAX." Several of my attendings are from Asia, and there is a language barrier. If I am having difficulty communicating with these doctors, I KNOW the patients are. Sometimes, I have to "translate" for the patients--the doctor's broken English for regular layperson's English. It's far worse when we have Spanish-speaking patients.

When I present a patient to an attending in clinic, they are filling out prescriptions after I've said about 2 sentences. I find myself reminding them of stuff all the time: "Hey, she needs a mammogram", "Hey, that prescription printed wrong", "Hey, don't forget her Kegel instructions", "Hey, she needs a breast exam", etc. I know these doctors function without med students most of the time, but that actually kind of concerns me. If you don't recognize that your English is a problem when you are talking to me, how can you see it as a barrier between you and your patients?

And the 5 minute visit? Ridiculous. Many of these patients are diabetic hypertensives taking 5 or 6 medications at once. It takes me 5 minutes just to review all the medications, make sure the patient is actually taking them, and see which ones they need refilled. My physical exam, as taught to me by the attending this month, consists of listening to the heart/lungs, the belly, quickly feel their legs (through their pants!) for edema, and look in their mouth. It's the 30 second physical exam. I realize the importance of a "focused" exam, but honestly, is this 30 second crap helping anybody?

We had an excellent lunch lecture last week where the speaker focused on the problems in primary care (not unusual), and offered potential solutions (which made it unusual). The 5 minute visit, coupled with the 20+ patient workday, isn't satisfying to patients or doctors. Some clinics are offering increased email, computer, and telephone services for simple questions and patient-controlled scheduling of routine care; for a yearly fee, you can email simple questions or med refills to your doctor; if you need to be seen, you get an appointment. As a result of fewer office visits, appointments are much longer when they need to be.

Putting more of this stuff on a computer program or email raises a concern to me of "outsourcing" these services to third world countries, where low-paid workers will man the telephone banks, doling out cookie-cutter medical advice much the same way as tech support. However, if we can avoid a lot of that, and truly offer quality interfacing between a doctor and his patients, I think this idea has a lot of merit.

I've often wished I had health care as good as my dog's. For a monthly $25 fee, he gets two full check-ups with blood work per year, one tooth-cleaning (with general anesthesia) per year, free office visits at any time, and discounted care for anything else. Why are we paying insurance companies thousands of dollars for inferior care, when we could have a direct arrangement with the doctor's office, and cut out the middle man? The doctor wouldn't have to hire as much staff to deal with the insurance, so overhead would go down, and fees would be affordable. Insurance could go back to being "catastrophe coverage", but routine healthcare would be covered.

Sure, it's not a perfect idea, but it's a start. And yes, I'm saying I'm totally dissatisfied with family medicine, at least as I'm seeing it now, at a large county clinic. Thank god for the procedures, or I'd go freaking nuts.

1 comment:

The Peanut Gallery said...

Great post! I just read it tonight and it really hit home - I felt like crap today and could not really make myself care for the patients in clinic like I usually do. It is scary how easy it was for me to be so focused on myself and sort of be an "automaton" like you said. And I agree with the "we treat the whole person" BS they feed you in family medicine. Yeah, freaking right.